What the flip flops on the individual mandate mean

Governor Mitt Romney is just four years too late. If he had beaten Senator McCain for the 2008 Republican nomination, the individual mandate would  have been front and center in the campaign; a ‘make the trains run on time’ corporatist approach to pooling health insurance risk that could save the country from the wild-eyed liberal schemes that Senator Obama would surely impose, yada yada. I am sure Gov. Romney would have taken tremendous glee in saying something like this over and over: “even Hillary Clinton has embraced the individual mandate that we successfully implemented in Massachusetts; only Senator Obama remains committed to a government takeover of health care that was rejected when Hillarycare was defeated.”

Of course, the ACA (aka Obamacare) with the individual mandate front and center came to not only be called a government takeover, but an assault on liberty and freedom itself. The Supreme Court will have their say in a bit, but it is worth asking what do the flip flops on the individual mandate mean more broadly?

The President did attack the individual mandate during Democratic primary, and it was about the only substantive issue that was different between the President and Sec. Clinton. However, in choosing to support the individual mandate he choose to embrace a practical strategy to pool risk that appeared to have bipartisan support and could therefore be passed. In doing so, the President demonstrated the commitment of progressives and their most closely allied political party to move toward universal coverage, even if it couldn’t be totally achieved in the ACA.

Conservatives, and their most closely allied party, the Republicans, showed that they have no overriding vision for health reform by their widespread flip flop on what had long been the conservative, responsible way to achieve reform. They have many ideas, but they are mostly used to argue against the advances of the other side. In short, they are great on defense, but seem to have no offense. Offense implies having an overall grand vision for health care, and a practical strategy to move toward this vision that includes the willingness to use political capital to achieve large or small victories moving toward an overall goal. The overarching vision for progressives is universal coverage. For conservatives, I have no idea what it is. Do you?

There are two requirements to ever having anything near a balanced budget again: an increase in taxes over historical levels, and some way of slowing health care cost inflation while also dealing with coverage and quality issues. The Democratic party and progressives are not perfect, but they have embraced the first and passed a beginning step toward the second. Without a cogent health reform plan, the Republican party has no plausible route to a sustainable budget. They need a deal on health reform terribly.

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

7 Responses to What the flip flops on the individual mandate mean

  1. Brian says:

    I think most conservatives believe the government should get out of providing healthcare for the non-poor entirely, including removing the deduction for employer coverage.

    While that could work in theory, it would never sell to a public that feels entitled to healthcare.

  2. Dear Don,

    I’m puzzled by one of your last statements. You claim that Democrats have “embraced” “an increase in taxes over historical levels”. Can you provide some details on this? As far I understand, President Obama and the Democrats in Congress have advocated retaining the Bush tax cuts for the middle class, as well as substantially reducing the payroll tax contribution. So how have they increased taxes over historical levels, and what historical levels?

  3. Don Taylor says:

    @Theodore Whitfield
    The past 40 years, taxes received have averaged about 18% of GDP. Per CBO’s take of the POTUS FY 2013 budget, this will be 19.8% of GDP in 2022 http://www.cbo.gov/sites/default/files/cbofiles/attachments/03-16-APB1.pdf (table 2, p. 3). In fairness, Ryan’s budget specifies 19% of GDP collected in taxes in 2030, so that is also an increase over historical avg of past 40 years. The Ryan budget is more speculative because it contains major changes to the tax code to achieve a result, but the details are not specified, and so cannot be assessed by CBO.

    That statement also has plenty of me assuming what the parties will be willing to do after the 2012 election in that statement. Keep in mind Fiscal Commission calls for tax receipts of 21% of GDP at the balance point in 2035, so neither of these budgets contains a realistic amount of revenue given a reasonable assumption on spending (assuming we care about deficits in the long term). The graph in this post shows fed tax receipts since 1971 as % GDP http://www.cbo.gov/publication/42527
    thx
    Don

  4. Brian Collins says:

    I agree that for liberals (and many moderates), universal coverage has been the unifying vision. For conservatives, I would say that promoting free markets is the unifying idea; they would argue that our health care problems are caused by too much government involvement, which explains why they promote plans to move Medicare more towards a private model, remove the distortionary tax deductions as the other Brian indicated (or allow individuals to get the same tax credit). One problem with this vision is that it doesn’t recognize the market failures that happen with health care and some of the things that make health care unique. Another problem with the vision is that it doesn’t recognize that the health care system grew up around the current structure of regulation and government programs, so we will never get to a pure free market system and have to deal with what is already there. I think the ACA does a reasonable job at dealing with reality, and future reforms that are successful need to be built on what we have. More payment reforms, led by Medicare, seem to be the way to go. Hopefully the demonstrations in ACA will work well and after an election cycle or two conservatives will be more open to a payment model that is less prescriptive and devolves responsibility closer to the local level. But maybe this is wishful thinking!

  5. Pingback: Liberal inconsistency on individual mandate « freeforall

  6. Pingback: Once Upon a Time, Liberals Hated the Individual Mandate - Forbes

  7. Pingback: What flip flops on the individual mandate mean for Dems and Repubs « The Reality-Based Community

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