On Friday I did something I almost never do: I tuned into Rush Limbaugh. And wouldn’t you know it? He was talking about one of my favorite subjects: Mitt Romney and health care reform.

Limbaugh was explaining why conservatives have such a hard time with Romney. It’s not that Romney lacks appealing qualities: On the contrary, Limbaugh described Romney “as a fine person … as nice a guy as you would ever run into.” The problem, Limbaugh said, was Romney’s refusal to apologize for signing a universal health care law in Massachusetts.

It’d be one thing, Limbaugh suggested, if Romney had expressed regret for signing that law. But Romney continues to stand by the Massachusetts law, including the dreaded individual mandate – the requirement that everybody with the means to pay for health care either obtain insurance or pay a fee to the government.

Romney’s only nod to conservatives is that he wouldn’t impose the law nationally, the way President Obama did when he signed the Affordable Care Act. According to Limbaugh, that’s not cutting it with conservatives: “That's why the polling data is what it is because people are troubled by his steadfast glue that keeps him attached to Romneycare, people don't like it because they do think it's much the same thing as Obamacare.”

I suspect Limbaugh is right about this. Many conservatives simply can’t get over Romney’s sponsorship of an individual mandate. But it also got me wondering about something else. Suppose health care reform, both the Massachusetts version and then the national version, included no mandate. Would Limbaugh and the rest of the right wing be happy? I doubt it.

Stop and think for a moment what universal health care entails. Unless you're willing to enact a single-payer plan -- which would be fine with me, but probably not Rush -- you have to regulate insurance companies pretty heavily. Among other things, you have to prohibit insurers from denying coverage to or raising premiums for people with pre-existing conditions.

In addition, you have to provide subsidies to lower- and middle-income Americans, so they have enough money to pay for their insurance, or you have to expand government programs for the poor, like Medicaid. That isn't cheap.

The Affordable Care Act calls for a little less than $1 trillion of spending on subsidies and Medicaid expansion in the first ten years. The law pays for that, in part, by imposing new taxes on the very wealthy and by taking some money away from the health care industry.

In other words, universal health care requires a lot of regulation and redistribution. Last time I checked, Limbaugh hates these things. So do his listeners.

And that's not all. If you want health care reform to reduce the cost of health care, as you should, then you also need to start changing the way we deliver medical care in this country.

Romneycare actually didn’t do this (although Massachusetts lawmakers are trying now) but Obamacare did – partly by cutting payments to private insurers that work with Medicare and partly by changing the financial incentives, in public and private insurance, that rewarded quantity over quality. I'm pretty sure Limbaugh hate these changes, as well. I know other conservatives do. 

Just to be clear, I'm not suggesting the individual mandate is irrelevant, as policy or as politics. If nothing else, it's given conservatives an easy and useful target, because it's the one part of health care reform most people understand.

But don’t be fooled. The primary reason Limbaugh and his listeners don't like universal health care is that they reject the basic concept. They simply don't believe in using government to make sure every American has access to affordable health care.