Liberal inconsistency on individual mandate

Avik Roy notes that most liberals have hated the individual mandate as a means of expanding health insurance coverage since the idea came about in the early 1990s, which is correct. As I wrote a couple of weeks ago, the flip flop on the individual mandate is telling for both conservatives and liberals.

For liberals and progressives, universal health insurance coverage is the holy grail, not just of health policy, but public policy. Many were willing to take the other sides idea becasue it was what could pass the House and the Senate and be signed by the President. They were willing to invest much political capital pushing the ACA even as they held their nose over many of the details, because it moved toward universal coverage.

The change of mind around the individual mandate is just as telling for Conservatives. I think the story that more Republican politicians were supportive of the individual mandate that rank and file conservatives, and conservative health policy types is likely true. For one thing, there really aren’t that many Conservative policy types that focus on health policy, and it is not a core issue that most conservative voters think a great deal about. And as Stuart Butler notes, one of the reasons that Republicans likely supported a mandate in the 1990s was so that they would have something with which to argue against the Clinton plan.

Progressives and liberals have shown a clear commitment to using any feasible approach to expand insurance coverage toward their ultimate health policy goal. Conservatives have mostly shown a clear commitment to arguing against the policies of progressives and liberals in the health policy realm. There is nothing about the historical record to suggest that Conservatives will be willing to expend political capital to advance a health reform proposal (briefly: idea, white paper, commerce and ways and means committee hearings and mark ups in the House, CBO, PR and political rallies, parsing of the plan by the other side, bazillion blog posts, full House vote, then to the SENATE!, etc).

I could be proven wrong and perhaps there will be a conservative health policy flourishing soon; only time will tell.

update: this is a fairly comprehensive and thoughtful piece from Capretta and Moffit on a replace strategy. Harold Pollack is blogging through it at TIE.

Stephen Carter on SCOTUS role

Stephen Carter’s op-ed on the role of the SCOTUS is the best, most nuanced take I have read.

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.

Stuart Butler’s change of mind

Stuart Butler of the Heritage Foundation had a piece in USA Today over the weekend defending his opposition to the individual mandate and the ACA in spite of advocating for an individual mandate in the past. In fact, virtually all of the undergrads in my Fall 2011 Intro to the U.S. Health System class identified Butler and the Heritage Foundation as the ‘intellectual fathers’ of the mandate in their final semester long research paper on the mandate and the ACA (post at semester beginning, follow up post at the end).

One of the most interesting things about Stuart’s piece in USA Today is that it doesn’t actually link to the initial document he wrote on the individual mandate in 1989 (his piece contains many other links). You can read it for yourself and his reasoning for changing his mind and then decide for yourself whether you think his (and Heritage’s) consistent and vociferous opposition to the ACA is consistent with their past views.

In Suart’s piece, he says there are three key reasons that his past support of an individual mandate does not make his current opposition ironic or inconsistent.

  • Deep Motivation. He says he supported an individual mandate to protect everyone else from the uninsured (cost shifting), whereas the motivation behind the ACA’s individual mandate is to get persons to purchase expansive coverage for themselves.
  • Corollary policies. He proposed modification of the tax treatment of employer paid insurance and then providing subsidy to encourage persons to purchase catastrophic insurance on their own, encouraged by an individual mandate. And instead of a penalty/tax as in the ACA, he says his preferred option was someone who did not comply would simply not get the subsidy to purchase insurance.
  • Tactical Motivation. The individual mandate was most actively pushed in opposition to the Clinton Plan, which had an employer mandate at its heart. Opponents of the Clinton Plan needed something through which to oppose the Clinton Plan, and the individual mandate fit the bill.

I completely believe the last reason noted above that motivated Butler and others to support the individual mandate in the past. On the first two, I am not so sure the distinctions warrant the degree of opposition to the ACA, but of course I can’t know the mind and motivations of another person, and my own perspective is cooked into that assessment. One of my goals as a blogger is to give people the benefit of the doubt (I like it when they do the same for me), and one thing I want to totally concur with Butler about is the correctness of being able to change one’s mind:

Changing one’s mind about the best policy to pursue — but not one’s principles — is part of being a researcher at a major think tank such as Heritage or the Brookings Institution. Serious professional analysts actually take part in a continuous bipartisan and collegial discussion about major policy questions. We read each other’s research. We look at the facts. We talk through ideas with those who agree or disagree with us. And we change our policy views over time based on new facts, new research or good counterarguments.

It is actually a bad sign if you never change your mind about anything. I appreciate Stuart giving an account for why he did so in this case, even if I don’t find it to be totally convincing.


How to Teach the Individual Mandate

I am teaching Public Policy 111 (Intro to the U.S. Health System)  for the ninth time this fall at Duke University. I love teaching this class of Freshman and Sophomores, and it is why I am a college professor. However, it has been hard to prepare for it this Summer because so much has changed since I last taught it in the Fall of 2008.  I didn’t even have a blog then!

However, the hardest part of preparing has been figuring out what to say about the individual mandate. I have always taught it in this course, and it was prominent in the “Republican health reform alternatives” section.  Some years I have had students read Responsible National Health Insurance by Mark Pauly, Patricia Danzon, Paul Feldstein, and John Hoff, the intellectual background behind why the mandate was the preferred Conservative approach. We talk about the Chaffee bill which was the Republican alternative to the Clinton plan in 1993-94 that contained an individual mandate to purchase coverage and set up state based insurance markets in which individuals could buy policies with income based subsidies. Wait…

Even as late as June 14, 2009, Senator Charles Grassley (R-IA) the ranking Republican on the Senate finance committee and member of the “gang of six” was saying on Fox News that the individual mandate was a bipartisan way to achieve health reform and he talked about the themes of responsibility and reducing cost shifting that have typically been the hallmark of Republican support. By the fall of 2009 he and most other Republicans had decided that an individual mandate was unconstitutional. I find the argument that “we were for it the past 18 years we just didn’t realize its passage would violate the Constitution” to be absurd. However, I don’t want to just get up and vent my spleen to the kids about this. So, I have decided to ask them. Each semester we have one long paper due at the end, and this year the topic will be as follows:

  • Trace the history of the individual mandate as a means of expanding health insurance coverage in the U.S. When did this idea emerge? Who/what groups were the intellectual drivers of the arguments behind the individual mandate?  What were the arguments in favor? In opposition? Why was the individual mandate often supported by Republicans and Conservatives in the past? Why do you think the individual mandate became a central part of the Affordable Care Act? When did the opposition to the individual mandate arise and why? From your research on the topic, are you persuaded that a federally-enforced individual mandate to purchase health insurance is acceptable under the Constitution or not? Why or why not?

I will write about their answers in December.



Is the individual mandate constitutional?

Great post by Jim Hufford on the Fourth Circuit’s hearing this week.