• “That’s the reason Democrats cooked up the individual mandate in the first place”

    Ezra Klein has a piece in the forthcoming New Yorker titled “Unpopular Mandate: Why do politicians reverse their positions?” He describes the evolution of Republican views on the individual requirement to purchase health coverage. He rightly notes that the mandate has been “at the heart of Republican health-care reforms for two decades.”

    There are some obvious reasons for their attention. Suppose we wish to protect every sick or injured American from the risk of financial catastrophe. We might accomplish this task in several way. Whatever we do, we must somehow address the possibility that people might gamble by going uncovered when they are healthy, and then seek to buy coverage under favorable terms when they get sick. It is a main concern of any serious national reform, particularly one that places heavy emphasis on individual coverage within the private insurance market.

    This Sunday’s Wall Street Journal editorial page takes up these issues, as it considered Republican responses to whatever the Supreme Court chooses to do. Journal editorial writers characterize the issue thusly (h/t @sahilkapur and @brianbeutler):

    If Republicans had any wit they’d consult the innovative work of the scholars Tom Miller and Jim Capretta on continuous insurance coverage and “guaranteed renewability” while still allowing insurers to price risk. Instead many of them want to maintain ObamaCare’s blanket pre-existing conditions rules, which is insane. That’s the reason Democrats cooked up the individual mandate in the first place, to help mitigate the cost spiral that these rules cause.

    I don’t happen to like Miller and Capretta’s approach. I worry about its implications for tens of millions of uninsured people. But consider the bolded words above. As Ezra’s piece describes in detail, the Journal’s little essay isn’t a precisely accurate accounting of the mandate’s pedigree. If you don’t believe him, you can get more details at this website:

    …the very idea of an individual healthcare mandate originated from the conservative think-tank The Heritage Foundation. But don’t take my word for it, read about it here.

    Moreover, many prominent conservatives have supported the use of the individual healthcare mandate. Some noteworthy conservatives who have supported individual healthcare mandates are:

    -President George H. W. Bush (source 1 and source 2)
    -Speaker Newt Gingrich R-GA (
    -Senator Orrin Hatch R-UT (
    -Senator Charles Grassley R-Iowa (
    -Senator Bob Bennett R-UT (
    -Senator Christopher Bond R-Missouri (
    -Senator John Chafee R-RI (
    -Rep. Bill Thomas R-CA (
    -And at least 16 other GOP Senators who have since retired from the Senate (

    Actually, in 1993 when then-President Clinton was attempting to reform healthcare, Republicans who opposed Clinton’s idea of an employer mandate, supported the idea of an individual mandate. An individual mandate, the Republicans argued, would be a “free-market solution” to reform healthcare, part of a “social contract” that would help people take responsibility for themselves and avoid the immorality of freeloading off the government. Clinton’s plan, on the other hand, was seen as a “true government take-over” of healthcare, the worst form of the dreaded “socialized medicine.”


    Romney is occasionally asked by the more conservative/libertarian voters, why he used an individual mandate. Romney replies:

    “The key factor that some of my libertarian friends forget is that today, everybody who doesn’t have insurance is getting free coverage from the government. And the question is, do we want people to pay what they can afford, or do we want people to ride free on everyone else. And when that is recognized as the choice, most conservatives come my way.”

    Yeah–that passage and the famous Romney quote are from mittromneycentral.com. This is a non-affiliated pro-Romney site where one can catch Romney’s schedule, read pro-Romney essays on diverse subjects. It has handy links to make Romney campaign contributions, buy “noboma2012” license plate covers, and more.

    Republicans’ gymnastics around the Affordable Care Act have been noteworthy, Yet as Klein observes, partisans of all stripes execute surprising substantive shifts that match their momentary political needs and that gin up suitably forgetful or hypocritical indignation regarding the centerpiece of an opponent’s presidency. Maybe that’s the zero-sum nature of the political game these days.

    It’s less forgivable when newspaper reporters and op-ed writers play by the same rules. The Wall Street Journal is a fine paper. Its news coverage enriches our country’s political and policy debate. Meanwhile, the Journal’s editorial page detracts from these same debates through Pravda-like intellectual dishonesty and gracelessness that reinforces our political system’s worst defects.

    • Why does the left always leave out the substantial opposition to the individual mandate? A small minority of Republicans briefly supported a stupid idea and now you want all of us to be obligated to support it forever?


      “In his May/June president’s message to contributors, Cato President Edward H. Crane lamented that “our friends at The Heritage Foundation have endorsed a mandated, compulsory, universal national health plan’ which flies in the face of the American heritage of individual liberty and individual responsibility.” Butler responded with an angry three-page letter deploring Crane’s gibe as ”just the latest in a series of pot-shots… Attacking Heritage for its alleged political incorrectness seems to have become a cottage industry at Cato and at NCPA.”

      Far more people on the right opposed it, even when it was first announced, then ever supported it.

      • Wait….
        The article is not protesting the idea that politicians can change positions, and is certainly not demanding that the right support individual mandates, it is simply pointing out the revisionist history present in that WSJ editorial.
        In fact, the very Avik Roy article you link to supports the main idea of the piece. Namely, that the WSJ article is falsely presenting the individual mandate as an idea created by democrats. From the Roy piece:

        “Based on my research, I see no contravening evidence to the claim that Stuart Butler and Heritage were the first people to advocate the individual mandate”

        And yes, there was conservative out-cry and debate when the idea was put forth (as noted in the Roy article). But it’s a huge leap from that to saying that “Democrats cooked up the individual mandate.”

    • While my political views are non euclidian, most of my friends would describe me as well left of most progressives. Nonetheless, I despise the individual mandate. The verbal gymnastics that those such as Klein go through in order to make it palatable as laughable- or would be if folks who read the new yorker had critical thinking abilities. First:
      1. Health insurance does not equal health care.Look at copays and deductibles and ask yourself whether the “uninsured” who could not afford premiums are going to be able to use the shockingly meager “insurance” that is being offered to them . Those who are forced to buy policies are going to be similarly disappointed.

      2. The mandate is an expansion of government power- the government can demand auto insurance as a price for driving on the roads but cannot force anyone to drive on the roads ( and those who do not do not need to purchase auto insurance even though a car may strike them as they walk on a sidewalk). The expansion here is “X” is good , therefore we can force private citizens to use their money to buy an inadequate product from private businesses. The commerce clause would have no limits if this was true legally ( some wish to interpret the commerce clause this way, rest assured there was never an intent to do that despite the convenience of the rationale for “good” goals).
      3. Our current system is a cruel abomination; despite this, the new law will, over the years result in higher costs and less accessibility for all. The sort of reform that is needed was not enacted in this bill;better to keep the current awful system because the new one will be worse.
      The fact that this failure was Obama’s should not concern “Liberals” in an election year because of the scary republican under the bedpost. It was his failure and if he is tossed out because of it and many other failures, so be it. Romney appears to be far stupider but its hard to believe he could be any worse. Of course in 2008 I said that about Bush.. the point is reflexive partisanship disguised as timely analysis is easy to spot Mr Klein.

    • Perhaps you do not understand the concept of an insurance risk pool.

    • Between 2002 and 2004 I served on the executive board for my parish. During one meeting the topic of our clergyman’s health insurance was raised. Our clergyman was relatively young, while the average age for clergymen in our denomination was growing older. A health insurance plan was available through the archdiocese, but its cost reflected the older average age of the clergymen it covered, and given the younger age of our clergyman we could easily find a less expensive policy on our own. Now consider the ramifications of every church in the archdiocese with a younger than average clergyman opting out of the Archdiocese plan. As younger clergymen left, the average age of the remaining clergymen in the plan would grow steadily older and their average health costs more expensive until at a certain point the cost of having an older clergyman would become simply unaffordable. Society, like the my parish cannot operate on pure self-interest alone. We all must make sacrifices for each other, so when the time comes that we are older and/or require assistance, it will be there for us. The individual mandate reflects this essential principle of fairness. I fear what kind of society we will become if we discard that.

      • If the Individual mandate accomplished anything close to what you suggest there might be an argument, it does not. An individual has a choice, a healthly person that is young, just getting by, and healthy because they take care of themselves can pay the same rate as a rich person in terrible health due to poor life choices like drinking, eating, and maybe a joint on the weekends, or pay 1/3 of a wealthy individual retired at 50 who also doesn’t take care of themselves….or pay a $100 penalty.

        We already know which option they choose. Your plea for sacrafice from the young healthy person who takes care of themselves is not accompanied by any plea from those that do not. You demand that peoiple that do the right thing subsidize those that do not. It’s called moral hazard, if I am not responsible for my poor decisions, even when they are in my control and will not mitigate cost it drives up the cost for everyone.

        That is why community rating fails EVERY time it is tried. That is why the absence of personal responsibility always results in failure.

        There is nohing fair about the individual mandate, by force of law it allows individuals to continue living unhealthy life and making inefficient decisions and stick the bill with someone else or future generations.

        • This is a ridiculous argument. There are *so many* health issues, both illness and injury, that are beyond the control of the individual. By your argument, we should let them die because they didn’t plan well enough to have lots of $$ lying around, just in case.

          Also, why do you think that monetary issues are going to motivate people to take better care of their health? If the risk of death doesn’t motivate them, hard to believe that anything will.

          • so many? Or maybe under 10-15% of the population suffers from an injury or illness of substantial monetary cost, $5,000 or higher. Even fewer of those are not preventable but either way insurance works very well for unlikly events. Only 5% of the population has ongoing medical conditions that run over multiple years. When you work with facts these arguments will make more sense to you.

            “Also, why do you think that monetary issues are going to motivate people to take better care of their health? If the risk of death doesn’t motivate them, hard to believe that anything will.”

            Then how do you propose we solve the cost problem….supposedly the whole reason we have reform. If your saying the 40 trillion in Medicare debt and escalating cost isn’t a problem and we should just insure everyone no matter the cost there really isn’t anything to talk about.

            • Nate: Your argument boils down to ,”Why do I have to support those bad people?” It’s always disappointing when people substitute shallow moralizing for actual analysis and critical thinking. The fact is that corporate America and our nation’s socioeconomic structure and polluted environment encourage many unhealthy behaviors and make us vulnerable to illness. This was highlighted in the PBS series unnatural causes, which I would encourage you to view.Here is the URL: http://www.pbs.org/unnaturalcauses/

              ” It turns out there’s much more to our well-being than genes, behaviors and medical care. The social, economic, and physical environments in which we are born, live and work profoundly affect our longevity and health – as much as smoking, diet and exercise”

            • Yes, we should create a system that covers everyone and follow the examples of nearly every other developed country in the world where all citizens are covered, are healthier and their costs are significantly lower than ours.

              We are hurting our job creation and productivity by failing to do so. As an example, my husband and I would desperately like to start our own business (create jobs!). However, since he had a heart attack and stents placed during his marathon training a couple of years ago, he is uninsurable. So we don’t create jobs. Maybe in 2014 if the powers that be don’t unravel the coverage guarantees of the ACA…

            • Nate, since you mentioned facts I’m kind of curious where yours are coming from. For example, where did you find the ‘fact’ that only 5% of the population has a medical condition lasting longer than a year? 8.3% of the US population has diabetes alone (http://www.diabetes.org/diabetes-basics/diabetes-statistics/) and that’s just one of many chronic illnesses. Please post your sources.

    • Lest we forget, the individual mandate was a Republican idea from the 90s.

    • I just don’t get all this effort to make the health insurance market work, when the issue isn’t health insurance, but health care. Why doesn’t the question move to ‘how should we fund health care?’ Then, maybe the answer won’t include health insurance at all and no one will have to worry about how to make the health insurance market healthy.

      • Health Insurance when it is really insurance, like the reinsurance market, works very well and is incredibly efficient. The problem is politicians bastardized insurance to the point today it isn’t insurance, i.e. covering annual wellness exams and preventive care, where is the risk transfer?

        80% of the population every year should not be receiving reimbursement from insurance, that would be a functional market.

        • Where does that statistic come from? According to every authoritative study, the distribution of health care expenditures is extremely skewed with a small percentage of the population drives the majority of costs,

          “In 2003, health care expenses among the U.S. community population totaled $895.5 billion. Medical care expenses, however, are highly concentrated among a relatively small proportion of individuals in the community population. As previously reported in 1996, the top 1 percent of the U.S. population accounted for 28 percent of the total health care expen-ditures and the top 5 percent for over half.”

          “The Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2002–2003”, Steven B. Cohen, PhD and William Yu, MA

    • Here is another:

      “A Small Proportion of the Total Population Accounts for Half of All U.S. Medical Spending
      Half of the population spends little or nothing on health care, while 5 percent of the population spends almost half of the total amount.2 In 2002, the 5 percent of the U.S. community (civilian noninstitutionalized) population that spent the most on health care accounted for 49 percent of overall U.S. health care spending. Among this group, annual medical expenses (exclusive of health insurance premiums) equaled or exceeded $11,487 per person.

      In contrast, the 50 percent of the population with the lowest expenses accounted for only 3 percent of overall U.S. medical spending, with annual medical spending below $664 per person. Thus, those in the top 5 percent spent, on average, more than 17 times as much per person as those in the bottom 50 percent of spenders.”

      The High Concentration of U.S. Health Care Expenditures
      Research in Action, Issue 19
      Agency for Healthcare Research and Quality

      • Not sure what you mean Dean, we are saying the same thing from the different side of the equation. Your saying a few percent equal the majority of claims and I am saying the majority of people incur a minority of claims. 50% of my population roughly doesn’t submit a claim any given year.

    • In my perfect world, the Democrats would accept the criticism that a mandate levies an unfair tax against the young and healthy.

      If a mandate forces a young person to spend $600 a month on community-rated health insurance — as happens in NJ and Mass — then that is an excessive tax.

      But in my perfect world, the Democratic alternative would be what Joseph White calls ” the International Standard.” (see his book Competing Solutions.)

      The International Standard is that people pay for health insurance according to their incomes — not age or health history.

      A young person in Germany pays 14% of income (shared with their employer). An older person in Germany pays 14% of income also.

      The young person making $20,000 a year in a starter job pays $2800.
      A young person making $200,000 a year will pay $28,000 for health insurance.

      The ACA takes some tentative steps in this regard with its subsidies in the health care exchanges. We need more of this.

      Bob Hertz, The Health Care Crusade

      • Aren’t you just replacing the current problem, people taking their chance and not buying insurance, and replacing it with a new one, tax avoidance? This system is only as good as your tax collection, we already know our tax collection is terrible. Your ability to collect taxes goes down the higher the tax burden.

        In Vegas and most big cities you have people making 6 figures paying tax on 30K under agreements with the IRS due to their inability to accurately audit tip income. It would be a failing system from the day it started.

        I personally have a major issue paying a substantial tax on my above to board income so every drug dealer, prostitute and other underground economy participants can get free healthcare.

        It is these convoluted solutions in attempts at social engineering that create all the problems.


        ” it shows the nation’s compliance rate is essentially unchanged at about 83 percent”

        Your system would be starting with a 17% underfunding/fraud problem. Not to mention it only increases the main problem we have today of cost, detaching risk from cost which fosters greater cost.

    • Nate, you are correct that ACA subsidy process will lead to tremendous gaming of the system. Right now America has I believe one of the highest rates of tax compliance in the world. The ACA could threaten this, which is about the last thing we need if we are going to deal with the federal deficit in any serious way. Just look at Greece or Italy for the combination of Swedish welfare and Latin American tax collections.

      This is why I have said for years that the best way to fund health reform is to increase the payroll tax. It has a very high compliance rate. Most firms use a payroll service, and the tax can be increased with the click of a computer.

      The payroll tax could be made more progressive — but that is a separate issue.

      Any government can help its citizens in one of two ways:

      a. raise taxes and give them services, i.e. Medicare


      b. help them buy services from the private sector, which also raises taxes but does so sneakily and we can say we are not socialists.

      We should go back to method a. Of course that is a political problem — a presidential candidate like me who stood up in debates and said. “I want to raise taxes to expand entitlements” would not win the debates.

      Bob hertz, The Health Care Crusade