Paul Ryan

Is the GOP's Flip-Flop on the Individual Mandate Any Different From Democrats' Flip-Flop on Medicare Reform?


In The New Yorker, Ezra Klein traces the history of the individual mandate to purchase health insurance, which began as a proposal by the conservative Heritage Foundation, and wonders why Republicans flip-flopped on the issue. The answer he settles on? Motivated cognition, "which Dan Kahan, a professor of law and psychology at Yale, defines as 'when a person is conforming their assessments of information to some interest or goal that is independent of accuracy'—an interest or goal such as remaining a well-regarded member of his political party, or winning the next election, or even just winning an argument." Republicans shifted positions, in other words, because it was politically convenient.

It's a nifty piece, nicely researched and enjoyable to read. But I have a few quibbles on his presentation of the history, and a bigger question: Couldn't you accuse Democrats of more or less the same thing when it comes to Medicare reform?

Let's start with the quibbles. Klein begins his piece with a brief backstory on the mandate: It first appeared as a proposal in a Heritage policy brief, then appeared in a 1993 bill cosponsored by 18 Republicans. All true, and genuinely damning to the GOP. But I think Klein goes slightly too far in writing that the mandate was "at the heart of Republican health-care reforms for two decades." This overstates the strength and depth of the Republican party's support for the policy. The 1993 bill was offered as an alternative to Bill Clinton's health care reform push at a time when some mostly moderate Republicans felt they had no choice but to offer a different plan. It wasn't even a purely Republican proposal: Democratic Senators John Kerry and David Boren also cosponsored the legislation. And it never gained widespread GOP support; it was never voted on or even formally debated.

The mandate was not then and did not go on to become a core policy for Republican legislators in Congress; it wasn't something any GOP elected official really wanted, that any of them would have traded anything or risked anything for. It was one part of one plan — a plan offered in a moment when a handful of Republican legislators felt like they had to offer something, anything — that never made it to a vote.

Were Republican elected officials deeply opposed to the mandate in the years between the mandate plan and President Obama's election? Probably not. But they certainly weren't making any push for it either. A number of the legislators who sponsored the original bill left office, and incoming legislators likely gave it little thought. At the national level, the Republican party wasn't particularly interested in the mandate one way or another because it wasn't particularly interested in health policy at all.

You can make a better case that the mandate remained quite popular amongst within the broader conservative policy community. Heritage continued to support the policy, as did Newt Gingrich's health policy shop. And they did eventually convince one Republican politician that the mandate was not only a useful alternative to counter the argument that the GOP has no health care plans, but an idea worth pursuing. That politician was the governor of Massachusetts, Mitt Romney, whose team insisted on a strong and clear mandate when drawing up plans for RomneyCare. Despite the GOP's current loathing of the policy, Romney still defends the mandate he signed in Massachusetts. But there are few if any other prominent Republicans who ever have risked anything to support the mandate, or made any noticeable effort to get one passed.

It was a policy that some conservative policy wonks were interested in, but never one that generated long-term devotion from the vast majority of party officials or legislators — which makes it a stretch to describe it as the "heart" of GOP health policy.

Democrats and liberal policy wonks took a similar turn with Medicare premium support, now championed in broad form by both GOP presidential nominee Mitt Romney and the party's leading policy entrepreneur, House Budget Committee Chairman Paul Ryan. The story is remarkably similar: The idea started out as a policy promoted by prominent liberal wonks, briefly gathered support from a handful of top-level policymakers near the end of the Clinton presidency, and is now deeply opposed by the majority of Democrats, who often refer to the idea as a plan to "end Medicare as we know it" — or occasionally just a way to "end Medicare," period.

Premium support, which would pay a flat rate toward the purchase of a private insurance plan for each Medicare beneficiary, was first developed by Alain Enthoven, a Democratic adviser who had previously served as a health policy consultant to President Jimmy Carter,  in "The History of Principles of Managed Competition" in 1993. In 1995, Henry Aaron, a scholar at Brookings who served as a senior official in President Carter's Department of Health, Education, and Welfare, gave the policy its name — premium support — and suggested that it represented a Medicare reform compromise, a "middle ground" that could retain Medicare's strengths but address budgetary challenges. In 1999, the National Bipartisan Commission on the Future of Medicare, which was chaired by Democratic Senator John Breaux and included Democratic Sen. Bob Kerrey, met to develop a proposal to reform the seniors' health entitlement. The first item in the final proposal put forth by Breaux and supported by Kerrey was "the design of a premium support system."

And just as Democrats saw hope for bipartisan agreement in the GOP's previous support for the mandate, Republicans like Paul Ryan saw hope for bipartisan Medicare reform in previous Democratic acceptance of premium support.

Was premium support the "heart" of the Democrats' Medicare reform plan for years? Not exactly. But it was developed by liberal wonks who served in Democratic administrations and supported in a national commission run by a Democrat. At least one Democratic Senator — Oregon's Ron Wyden — still supports the plan, as does former Clinton budget adviser Alice Rivlin.

Yet for the most part the party's legislative leadership and rank and file have become deeply opposed to the idea in recent years, with liberal activists famously running an ad comparing Paul Ryan's Medicare overhaul to pushing a wheelchair-bound grandmother off a cliff, and the "ending Medicare" talk common amongst prominent Democrats. Even Henry Aaron now argues against implementing premium support any time soon.

Would opposition have been so vehement, so ugly, so powerful back when the policy was understood as a creation of Democrats? Did Democrats develop and strengthen their opposition in response to Paul Ryan's plan? Were they "conforming their assessments of information to some interest or goal that is independent of accuracy" — perhaps with the goal of villifying Ryan's plan in order to help them win the next election? No doubt some changed their minds after thoughtful consideration, and others strengthened opposition where little feeling or opinion of any kind had existed. But it also seems likely that Democrats adjusted and developed their stances because it was politically convenient, just as Republicans did.