More on Butler and the individual mandate

Kenneth Thomas has a nice post on Stuart Butler’s change of heart on the individual mandate. I think he and Aaron think I was too easy on Butler, and Ezra Klein likely concurs, especially given the timing of Butler’s switch.

One point from Butler’s USA Today piece that I want to highlight and comment on:

So why the change in this position in the past 20 years?

First, health research and advances in economic analysis have convinced people like me that an insurance mandate isn’t needed to achieve stable, near-universal coverage. For example, the new field of behavioral economics taught me that default auto-enrollment in employer or non-employer insurance plans can lead many people to buy coverage without a requirement. [emphasis mine]

The thing I most hold against Butler and many other conservatives is the degree and vociferousness of their opposition to the ACA given their past positions. A reasonable, policy based opposition might have gone something like “I used to support the individual mandate, but no longer think it is the best approach. Instead of an individual mandate, we should use auto-enroll procedures to attain the needed risk pooling. The CBO should estimate how different the individual mandate is from aggressive auto enroll procedures.”

Instead, the individual mandate was painted as an unimaginable affront to the Republic, etc. etc. and this had the effect of moving us away from the policy.

Interestingly, the first comprehensive reform bill introduced into the 111th Congress (on May 20, 2009, about a month before the first version of HR 3200 was reported out of any House committee) was the Republican sponsored Patients’ Choice Act (PCA), that had at its heart the use of auto-enroll procedures to achieve risk pooling.

It was introduced by Reps. Paul Ryan and Devin Nunes, and Sens. Tom Coburn and Richard Burr. This plan proposed altering the tax treatment of employer paid insurance, providing individuals with money to defray the cost of buying private insurance in state based exchanges, and advocated auto-enroll procedures such as signing persons up by default when they renewed their drivers license or paid state income taxes. There are some big problems with this bill, however, there are similarities with the ACA that suggest that a deal could be possible in policy terms.

The PCA has never been scored by CBO. I have written that I would like to know how different auto enroll procedures would be from the weak individual mandate contained in the ACA, in terms of insurance expansions.

Given that Stuart Butler has included his interest in auto-enroll procedures as a reason for no longer supporting an individual mandate, I would love for him to join me in calling for the sponsors of the Patients’ Choice Act (one of them is my senior Senator) to provide the details necessary for the CBO to score their bill. This would provide us with some sense of the relative effect of auto enroll procedures vs. an individual mandate in expanding insurance coverage. Who knows, we might accidentally stumble upon a compromise.

DT

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

6 Responses to More on Butler and the individual mandate

  1. Not entirely on topic, but I’m wondering if you have thoughts on the employer mandate to provide free access to contraception services. My thought is the Obama administration has chosen not to give Catholic institutions the workaround the president promised because it would be making a concession on a mandate in the ACA which would undercut its legal argument for the individual mandate.

    • Don Taylor says:

      @John B Chilton
      I haven’t followed the contraception dust up closely and haven’t looked at the language in the parts of the bill in question. I need to do so before commenting

  2. Brad F says:

    Don
    On the behavioral economics front and auto-enroll, I am not so sure that conservatives of every stripe would embrace.

    You probably have read Nudge, and the ideas within may be perceived as paternalistic and overbearing.

    Lets take a reworked CLASS–a more financially viable version for the sake of argument. What if we made it auto-enroll as default, with an active opt out. Would Stuart find this palatable, or would he or others find this objectionable and an affront to liberty?

    See where I am going here?

    Brad

  3. Don Taylor says:

    @Brad F
    you are correct, that CLASS is flawed because of lack of risk pooling and auto enroll (or even simply underwriting) could fix it. Perhaps auto-enroll is just the next ‘what we are for to oppose something else.’ If you are against govt insurance, an employer mandate, an individual mandate, and then against auto-enroll/behavioral stuff, there is not really anything left if you claim to what to expand insurance coverage

  4. Will says:

    I just wrote a post about the mandate and the opt-out alternative on my blog, here:

    http://dr-souz.blogspot.com/2012/02/does-aca-require-individual-mandate.html

    For those who are wary of clicking, I’m talking about the flaws in the Supreme Court doing this now, 2 years later and the technocratic implications of some of the alternatives.

  5. Chris says:

    Wait a minute. So the leading health policy guru at the conservative Heritage Foundation now supports the government selecting and forcibly enrolling (yes, that’s what default auto-enrollment means) people into certain health plans or coverages is better than requiring that people choose a health plan for themselves? Doesn’t that seem…well…like a more extreme version of the individual mandate? A one-size fits all, government dictated approach. Confusion reigns.

    Methinks that Mr. Butler and Heritage and scrambling to get out from under the responsibility that they rightly bear for RomneyCare and ObamaCare. Does anyone believe that if the Democrats’ initial offer had been single payer that the Republicans counter-offer wouldn’t have been exchanges, tax credits, and an individual mandate? In short, no.

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