Destroying Conservative-Style Reform: GOP Turns on Insurance Mandate at Its Own Peril

In January 2009, Mitt Romney penned some advice to incoming President Barack Obama regarding health care reform in a USA Today op-ed piece. Romney suggested Obama look to “the lessons we learned in Massachusetts,” in contemplating federal-level reform, noting specifically:

First, we established incentives for those who were uninsured to buy insurance. Using tax penalties, as we did, or tax credits, as others have proposed, encourages ‘free riders’ to take responsibility for themselves rather than pass their medical costs on to others.

The Massachusetts reform aimed at getting virtually all our citizens insured. In that, it worked: 98 percent of our citizens are insured, 440,000 previously uninsured are covered and almost half of those purchased insurance on their own, with no subsidy.

In a January 2008 GOP Presidential Primary debate, Romney underscored his belief that the insurance mandate should be applied at a national level. When the moderator noted, “Romney’s system has mandates in Massachusetts, although you backed away from mandates on a national basis,” Romney interjected, “No, no, I like mandates. The mandates work.”

I previously posted a video clip, which showed Romney giving his support to the notion of applying ‘Romneycare’ at a national level.

As it becomes more and more apparent that Romney will become the GOP nominee for president, the irony of the GOP’s rabid opposition to the 2010 Affordable Care Act has reached a point of intellectual absurdity. Romney’s continual caustic criticism of Obama’s signature domestic achievement is disingenuous at best. Frankly, the high number of seismic shifts in Romney’s political paradigm and their suspiciously coincidental timing with GOP election contests in an ever-more-conservative Republican base, has long caused me to lose confidence in Romney as a candidate with the kind of exceptional integrity you would expect from a former LDS bishop and stake president. That so many conservative GOP primary voters have partaken of the proverbial Romney ‘cool-aid’ in whole-heartedly accepting his sudden shifts on countless major political issues and voted for him has surprised me.

But getting back to health care reform, David Frum, a former speechwriter for President George W. Bush, made an astute observation last week, as the Affordable Care Act was debated at the Supreme Court. He noted how Romney “did the heavy lifting [in 2006] to prepare Republicans for this moment,” where the GOP urgently needs to provide a response to the health care crisis in America, and not just be the party that simply says “no” to everything proposed by the Democrats without providing an alternative solution. Frum noted,

[Romney] readied himself to fight an election as a Republican presidential candidate who not only accepted the ideal of universal coverage, but who had actually delivered it. That would have been quite a story to tell. Had things gone slightly differently in 2008, it might right now fall to President Romney's Solicitor General Paul Clement to explain to a sympathetic Supreme Court why the mandates in Romneycare in fact are constitutional.

A central component of Obamneycare is the mandate requiring all citizens to purchase health insurance coverage or face a fine. Without the mandate, popular measures in the bill like the prohibitions on insurance companies from denying coverage to those with pre-existing conditions, would not be financially feasible without bankrupting the health insurance industry. The mandate is key to what used to be the principle Republican and conservative counter-proposal on health care reform, which relies on private insurance providers rather than a government-run health care financing system. Obamneycare is the brainchild of the ultra-conservative Heritage Foundation, which proposed such a system in detail back in 1989, with the following hypothetical as an underlying justification:

If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance. If we find that he has spent his money on other things rather than insurance, we may be angry but we will not deny him services — even if that means more prudent citizens end up paying the tab. A mandate on individuals recognizes this implicit contract.

Princeton economist Paul Krugman recently wrote, 

When people don’t buy health insurance until they get sick — which is what happens in the absence of a mandate — the resulting worsening of the risk pool makes insurance more expensive, and often unaffordable, for those who remain. As a result, unregulated health insurance basically doesn’t work, and never has.”

There are at least two ways to address this reality — which is, by the way, very much an issue involving interstate commerce, and hence a valid federal concern. One is to tax everyone — healthy and sick alike — and use the money raised to provide health coverage. That’s what Medicare and Medicaid do. The other is to require that everyone buy insurance, while aiding those for whom this is a financial hardship.

Is requiring that people pay a tax that finances health coverage OK, while requiring that they purchase insurance is unconstitutional? It’s hard to see why — and it’s not just those of us without legal training who find the distinction strange. Here’s what Charles Fried — who was Ronald Reagan’s solicitor general — said in a recent interview with The Washington Post: "I’ve never understood why regulating by making people go buy something is somehow more intrusive than regulating by making them pay taxes and then giving it to them."

As I pointed out in a previous post, many prominent Republicans were strongly in favor of this kind of system, at least until it was embraced by a Democratic President. These included LDS Senators Orrin Hatch and Mike Crapo, as well former (and soon-to-be-former) GOP Presidential candidates Tim Pawlenty and Newt Gingrich. It seems that many Republicans oppose the health care reform bill simply because it was signed into law by a Democrat.

Ironically, if the Supreme Court overturns the mandate, they may hasten the arrival of a health care system that relies significantly more on the federal government, like a single-payer, “Medicare-for-all” system. Justice Anthony Kennedy hinted last week that it might be more “honest” if government simply used “the tax power to raise revenue and to just have a national health service, single-payer.” Like President Reagan’s former solicitor general, I do not see why conservatives today would challenge the constitutionality of the insurance mandate when the alternative is a more government-heavy system. And if it is overturned, prospects for privatizing Social Security, an extremely popular idea among conservatives that was championed by President George W. Bush, will be dead. If the government cannot require you to buy health insurance, then how can they require you to put money into private investment accounts? In their frenzied attempts to defeat Obama at every step, Republicans are shooting themselves in the foot.

President Obama admitted early on that had circumstances been different, he would have preferred to create a single-payer health care system in the U.S. Across the developed world, single-payer systems have proven to be far more efficient at delivering quality universal care. For more discussion on cost comparison to health care systems in other countries, see this earlier post.

David Frum, a conservative himself, warned Republicans that they need to come up with a better plan, regardless of which way the Supreme Court moves on the Obama health law. He sardonically summarized the current GOP strategy on Obamneycare:

Our plan is to take away the government-mandated insurance of millions of people under age 65, and replace it with nothing. And we're doing this so as to better protect the government-mandated insurance of people over 65—until we begin to phase out that insurance, too, for everybody now under 55.

The GOP primary voters, who are “overwhelmingly over 65 and happily enjoying its government-mandated and taxpayer-subsidized single-payer Medicare system,” will matter far less in the general election, because “the general-election electorate doesn't have the benefit of government medicine. It relies on the collapsing system of employer-directed care.”

If the mandate is overturned, both sides need to come up with an alternative solution to solve the health care free-rider problem that does not entail simply letting uninsured sick people suffer and die