The Parallel Origin Stories of Premium Support and the Individual Mandate


It's true, as Kevin Drum writes in a post on political hypocrisy, that remaking Medicare as a premium support program was never a major priority for Democrats. But that's a big part the point I was trying to make yesterday in comparing comparing the GOP's fluid position on the individual mandate to Democrats' position on Medicare reform: Republican support for the mandate, while real, was never that strong either.

I agree with much of Drum's post, but says my case is "a little weak" because "premium support never really had much liberal support in the first place." But broad Republican support for the mandate wasn't all that strong either, and that's a big part of why the comparison between the two is useful.

Let's look at the similarities between both:

The Mandate: Conservative policy wonks at the Heritage Foundation develop the idea for the individual mandate in 1989.
Premium Support: Alain Enthoven, a liberal policy wonk who had worked as a health consultant for Jimmy Carter, develops the idea for premium support in 1993. In 1995, Another liberal policy wonk, Henry Aaron, develops the idea further and gives it a name.

The Mandate:  In 1993, a bipartisan group of legislators led by GOP Senator John Chafee, and including a total of 18 Republicans, sponsors a go-nowhere health care bill with a mandate that is never formally debated or voted on.
Premium Support: In 1999, a bipartisan commission on Medicare reform led by Democratic Senator John Breaux puts forth a go-nowhere proposal to reform Medicare as a premium support program. 

The Mandate: In the late part of George Bush's second term, a handful of Democrats begin a push for health care reform based in large part on regulated private insurance and a mandate — a plan they hope some Republicans will accept based on previous party support.
Premium Support: In the late part of George Bush's second term, a handful of Republicans begin a push for Medicare reform based on premium support — a plan they hope some Democrats will accept based on previous party support. 

The Mandate: During the Obama presidency, Republicans broadly unify around vehement opposition to ObamaCare's federal mandate. A few Republicans, most notably Mitt Romney but also Scott Walker, suggest that states might pursue their own mandates.
Premium Support: During the Obama presidency, Democrats unify around vehement opposition to Paul Ryan's premium support plan. A few Democrats and liberal wonks, most notably Oregon Sen. Ron Wyden and former Clinton budget chief Alice Rivlin, continue to endorse premium support plans. 

The parallel is not perfect, but it is close enough to be useful. In both cases, it's easy to imagine the eventual opposition never developing. Indeed, just as it's easy to imagine that many and perhaps even most Republicans might have one day come to support a mandate, it's relatively easy to imagine that Democrats might have developed real fondness for premium support. 

Missing from this timeline, of course, is Mitt Romney's health care overhaul in Massachusetts, which relies on the same basic structure as ObamaCare, including a mandate, as well as scattered statements in favor of the mandate over the years, especially in relation to RomneyCare. A number of Republicans who now oppose the mandate — like Sen. Jim DeMint, for example — came out in favor of Romney's health care overhaul before it became an item of national controversy. And as Ezra Klein points out in response to my post, Republicans like Lamar Alexander and Chuck Grassley also spoke favorably of the mandate as late as the summer of 2009.

But Romney is the only Republican politician to show a true commitment to the mandate, to take any risks or expend any significant political capital in an attempt to see the policy passed. For the rest, it was an easy, off-the-shelf plan that Republican legislators could point to in order to claim they had a health care plan without actually have to think seriously about health care policy. Republicans weren't particularly opposed to the mandate, but they weren't working particularly hard to pass one either.

Because the fact is that Republicans have never much care about the details of health care policy. They supported the mandate because it was there, because it was easy, and because without it, they had nothing. Which is about where they are today. It's why despite the party's broad opposition to a mandate, rising star Scott Walker still mumbles about states implementing their own ObamaCare-style insurance regulations and suggests that state-level coverage mandates might be part of the equation, why earlier this year Republicans in Congress gave up on their plan to announce a health care alternative, and why the best that Senate Majority Minority Leader Mitch McConnell can do when asked about the potential GOP policy response to the Supreme Court striking down some or part of ObamaCare is to say that Congress should just start over. He doesn't have any answers, and neither does his party.

This isn't a party that was devoted to the mandate, or cared about the particulars of health policy at all — not in 1993, not in 2009, and not now.