February 7, 2012
THE MANDATE BEFORE CONSERVATIVES BECAME DERANGED:
The Tortuous Conservative History of the Individual Mandate (Avik Roy, 2/07/2012, Forbes)
The UR can never be forgiven making a conservative health care plan the centerpiece of his presidency.It all started with a piece of legislation passed in 1986 by a Democratic House and a Republican Senate and signed by Ronald Reagan, called the Emergency Medical Treatment and Active Labor Act, or EMTALA. [...]EMTALA, one of the great unfunded mandates in American history, required any hospital participating in Medicare--that is to say, nearly all of them--to provide emergency care to anyone who needs it, including illegal immigrants, regardless of ability to pay. Indeed, EMTALA can be accurately said to have established universal health care in America--with nary a whimper from conservative activists. [...][S]ome conservatives, seeking a more market-oriented path to universal coverage, began endorsing an individual mandate over an employer mandate. An individual mandate would address the "free rider" problem caused by EMTALA, by requiring people to buy their own insurance. In addition, moving to a more individual-based system from the employer-based one would significantly increase the efficiency of the health-insurance market.With these considerations in mind, in 1989, Stuart Butler of the Heritage Foundation proposed a plan he called "Assuring Affordable Health Care for All Americans." Stuart's plan included a provision to "mandate all households to obtain adequate insurance," which he framed explicitly as a way to address the "free rider" problem and employer mandates (emphasis added):Many states now require passengers in automobiles to wear seatbelts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement.This mandate is based on two important principles. First, that health care protection is a responsibility of individuals, not businesses. Thus to the extent that anybody should be required to provide coverage to a family, the household mandate assumes that it is the family that carries the first responsibility. Second, it assumes that there is an implicit contract between households and society, based on the notion that health insurance is not like other forms of insurance protection. If a young man wrecks his Porsche and has not had the foresight to obtain insurance, we may commiserate but society feels no obligation to repair his car. But health care is different. 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. Society does feel a moral obligation to insure that its citizens do not suffer from the unavailability of health care. But on the other hand, each household has the obligation, to the extent it is able, to avoid placing demands on society by protecting itself...A mandate on households certainly would force those with adequate means to obtain insurance protection, which would end the problem of middle-class "free riders" on society's sense of obligation. [...]In 1992 and 1993, some Republicans in Congress, seeking an alternative to Hillarycare, used these ideas as a foundation for their own health-reform proposals. One such bill, the Health Equity and Access Reform Today Act of 1993, or HEART, was introduced in the Senate by John Chafee (R., R.I.) and co-sponsored by 19 other Senate Republicans, including Christopher Bond, Bob Dole, Chuck Grassley, Orrin Hatch, Richard Lugar, Alan Simpson, and Arlen Specter. Given that there were 43 Republicans in the Senate of the 103rd Congress, these 20 comprised nearly half of the Republican Senate Caucus at that time. The HEART Act proposed health insurance vouchers for low-income individuals, along with an individual mandate.Newt Gingrich and Rick Santorum, who were both House backbenchers in 1993, were also in favor of an individual mandate in those days. (Gingrich continued to support a federal individual mandate as recently as May of last year. We don't know much about the timing of Santorum's change of heart.)It would seem that 1990s conservatives weren't concerned with the constitutional implications of allowing Congress to force people to buy a private product. "I don't remember that being raised at all," Mark Pauly told Ezra Klein last year. "The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax...So I've been surprised by that argument."
Posted by Orrin Judd at February 7, 2012 6:50 PM