The GOP and the Health Insurance Mandate
With the health insurance individual purchase mandate looking more vulnerable than ever, Democrats are trying desperately to get some mileage out of the fact that it was Republicans who first proposed the idea. Washington Post blogger Ezra Klein posted an interview yesterday afternoon with University of Pennsylvania economist Mark Pauly, who is sometimes identified as the “father of the individual mandate.” Klein writes:
“Pauly was the lead author of a Health Affairs paper attempting to persuade President George H.W. Bush and his administration to adopt a universal health-care proposal that would keep the government from eventually taking over the sector. … At the heart of that strategy was the individual mandate, which would go on to be promoted by congressional Republicans, the Heritage Foundation, and Massachusetts Gov. Mitt Romney before being adopted by Democrats and becoming a bete noire of conservatives.”
It’s true, of course, that Republicans seized on the purchase mandate idea, as Pauly suggests, “because we were concerned about the specter of single payer insurance, which isn’t market-oriented, and we didn’t think was a good idea. One feature was the individual mandate. The purpose of it was to round up the stragglers who wouldn’t be brought in by subsidies.” In a 1991 paper published in the journal Health Affairs (pdf), Pauly and his co-authors wrote that, “Our view is that excessive government intervention will make matters worse. … Our strategy, therefore, is to design a scheme that limits governmental rules and incentives to the extent necessary to achieve the objectives.”
The GOP bit into it hook, line, and sinker. But a little context is necessary.
In November 1991, Democrat Harris Wofford beat expected favorite Dick Thornburg in a special election to replace deceased Pennsylvania Senator John Heinz in 1991, running primarily on a platform centered around universal health care. And the following year, Bill Clinton won the presidency after making universal health care a central feature of his campaign. There was genuine fear among Republicans that First Lady Hillary Clinton’s Health Care Task Force would propose legislation that included a single payer plan, so Republicans scrambled to design their own proposals that would be “less bad.”
Republican Senator John Chaffee introduced the Health Equity and Access Reform Today Act, and Republican Senator Don Nickles and Rep. Cliff Stearns introduced the Consumer Choice Health Security Act, both of which contained an individual health insurance purchase mandate and attracted dozens of Republican co-sponsors. (As an aside, Democrats have seized on liberal Republican Chaffee’s bill as an example of conservative hypocrisy while ignoring the bill introduced by actual conservatives Nickles and Stearns. It’s not clear why this is. Perhaps just laziness, but maybe I’m just reading into things?) And, as has been pointed out repeatedly, the conservative Heritage Foundation entertained a similar feature, and then Massachusetts Governor Mitt Romney also included a purchase mandate in his state’s health care overhaul, for which both should be roundly condemned.
It’s worth noting, though, that most of us in the free market movement have never embraced the health insurance purchase mandate. And I’m proud to dig out of the archives an old Cato Institute paper (pdf) written by my former CEI colleague Tom Miller (now at the American Enterprise Institute), which roundly criticizes the 1993-94 Republican compromise legislation. Tom found a lot of faults in those bills, and he singled out the individual purchase mandate as being especially egregious. While acknowledging that, from a political perspective, “any legislative alternative to the Clinton plan must guarantee universal coverage,” he wrote:
The most troubling aspect of the Nickles-Stearns legislation, as introduced on November 20 , is the mandate that it imposes on all Americans to purchase a standard package of health insurance benefits. By endorsing the concept of compulsory universal insurance coverage, Nickles-Stearns undermines the traditional principles of personal liberty and individual responsibility that provide essential bulwarks against all-intrusive governmental control of health care.
Tom concluded that, “By failing to provide a clear alternative based on market principles, Nickles-Stearns blurs opposition to Clinton-style health care legislation. By focusing the political debate on the wrong issues, it opens the door to extensive political interference in private health care decisions.” Indeed.