by Robert I. Field, Ph.D., J.D., M.P.H.

What exactly is socialized medicine?

In 2007, Mitt Romney offered his definition. Referring to uninsured patients, he said: “When they show up at the hospital, they get care. They get free care paid for by you and me. If that’s not a form of socialism, I don’t know what is.”

He was defending his Massachusetts reform plan as a market-based alternative.

However, since then, he has apparently come to regard socialism more favorably.

Last month, he told the TV show 60 minutes that we don’t need health reform because: “If someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance and take them to the hospital and give them care. And different states have different ways of providing for that care.” He made similar remarks to the Columbus Dispatch last week.

That is the same system he referred to as socialism five years ago.

Why would Romney defend such an arrangement? Has he become a socialist? It seems improbable.

Perhaps he has forgotten everything he knew about hospital emergency care when he was governor of Massachusetts. Since misconceptions are common, some background on how the system actually works may be helpful. 

Federal law requires hospital emergency rooms to see all patients without regard to their ability to pay. The law is called the Emergency Treatment and Active Labor Act, or EMTALA for short. 

But seeing patients is not the same as actually treating them. EMTALA requires hospitals to assess all patients to decide whether they are experiencing a true emergency and to stabilize them when they are. However, if there is no actual emergency or the patient is stable enough to be discharged, the hospital is not obliged to do anything more. They do not have to provide a full range of care. 

In other words, if someone has a heart attack, a hospital must diagnose the condition and provide just enough care to stabilize it. Beyond that, the hospital can, and in most cases will, refuse to go any further unless the patient has insurance. If an uninsured patient wants additional care, he will have to wait to have another heart attack to get it.

And these limited services are not free. The heart attack victim will receive a bill. Those who are very poor may be let off the hook, but hospitals will pursue middle class patients for payment, often in court. For those without health insurance, an emergency room visit can, and often does, lead to bankruptcy.

It is true that emergency rooms are often used as free clinics for routine ailments. But only by patients who are truly indigent, and the services they receive are extremely limited. There is no ongoing or elective care.

As if that isn’t bad enough, the system could hardly be more inefficient. Emergency rooms are the most expensive place to provide care. And relying on them means delaying treatment until a crisis has arisen. That is when it is most difficult to provide, and often when it is too late to do any good.

That is one reason why lack of health insurance leads to tens of thousands of deaths each year, as noted by my colleague Michael Yudell in The Public’s Health blog.

And, of course, letting the poor use hospitals for free, even when they only receive limited care, turns them into public clinics. Romney was right back in 2007. That is socialized medicine.

Fortunately, there is a market-based alternative. It is the approach Romney supported when he was governor of Massachusetts and that Congress enacted as law in 2010. It is the plan we now call Obamacare.