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.


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.