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. 

NEXT: Ronald Bailey Wanders Through the People's Summit at the Rio +20 Earth Summit

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  1. Today, Republicans disingenuously pretend that selling across state lines and tort reform will fix healthcare. Proof that they have no interest in such.

    1. Because any idea that merely helps and doesn't solve every problem should never be pursued.

      1. Better than your presidents' plan, shrike.

        Oh, and fuck Romney, too.

      2. You want the federal government in tort reform? The states are doing fine at it.

        Same with selling across state lines? Don't states have the right to determine insurance rules?

        1. No they don't. Not if Congress decides differently. It is called the negative commerce clause.

          And some states are doing tort reform well. But the blue states that are filled with retarded people like you are not. And that is driving up the cost for everyone. It is the perfect and appropriate situation for Congress. People in intelligent states like Texas should not have to pay for the mistakes of people in backward states like California and New York.

        2. Don't states have the right to determine insurance rules?

          Yes they do. In their jurisdiction. What they shouldn't have, that the Federal Govmt could easily fix, is the right to prevent their citizens from buying their healthcare out of jurisdiction. This would increase competition. (that's a good thing, in case, in your role as pretend capitalist, you didn't know that).

          1. the rightpower to prevent their citizens from

            my bad

    2. Today, Republicans disingenuously pretend that selling across state lines and tort reform will fix healthcare.

      What's broken with health care?

      Oh, did you mean health insurance?


  2. The only health policy that they cared about was HSAs, which is why HSAs were essentially the price that many of the Republicans insisted on as part of the Medicare Part D law.

    As you've noted, HSAs (which require high deductible plans) appear to be working effectively. But indeed perhaps they're not enough.

    1. Team Blue hates HSAs. Irrationally, even viscerally.

      1. Yes, they do. But I still find it curious that Peter can write articles praising them (and the pairing with high deductible plans) without mentioning the law that created them. Or that he can discuss Republican health care strategy without mention actual Republican health care achievements (both good and bad.)

        I can list to an argument that HSAs don't work, and I can listen to an argument that the effect of the 2003 law was relatively minor in encouraging the shift to high deductible plans, though I'd dispute both arguments. But why the omission?

  3. So is it Drum's opinion that Republican support for an idea makes it a priori constitutional? If not, then what the hell difference does it make who did or did not support the mandate?

  4. Cheap partisan tries to score cheap partison points. Disregards facts and distorts others' views in the process.


    1. It is sad to see Reason fall into the "if the person making the argument is a hypocrite the argument must be invalid" fallacy.

      1. Even Hitler had an amazing idea.

        Fortunately, it was his very last one.

        1. there something about trains too, wasn't there?

  5. "why the best that Senate Majority Leader Mitch McConnell can do"

    Pretty sure Harry Reid is surprised by this. He wasn't expecting it until January. 🙂

    1. Ah, fixed!

  6. Here's Peter wondering if HSAs and CDHPs were making the health care cost curve bend. Far from the only article he's written about them. And yet I don't believe I've seen a word about how they were created and encouraged by the Medicare Part D law.

    I think that on balance the Medicare Part D law was not worth it. But surely any discussion of how HSAs and CDHPs may be bending the cost curve should mention the law. And HSAs should surely be brought up as part of the Republican strategy on health care, even if only to dismiss their effectiveness the way that tort reform and selling across state lines is dismissed.

    1. shrike already schooled us on tort reform and selling across state lines, so we might as well drop those subjects and go back to licking Team Blue boots like he does.

    2. even if only to dismiss their effectiveness


      1. I think that they're effective. Peter thinks that they're effective.


        1) He writes articles talking about what the GOP strategy on health care has been for the past 20 years, and ignores HSAs entirely, despite praising their effects elsewhere.

        2) He writes articles praising HSAs and high deductible health care plans without mentioning at all the law that created HSAs and required high deductible plans with them, and gave tax benefits. It is akin to noting an increase in people buying health insurance, or rates, or any other change in MA while ignoring Romneycare.

        All I'm saying is that the omission of HSAs here and elsewhere by Peter would be more understandable if he dismissed their effectiveness, but he doesn't. I am confused.

      2. I'd be more satisfied if Peter simply included a line in *one* of his articles saying something, "Yes, the GOP implemented HSAs as one of their health care strategies, but..." and whatever his objection was. (They don't work, are not enough, the 2003 law was only to a minor degree responsible for their spread, etc.)

        1. Is getting rid of a ban really a "strategy" in the sense you seem to be using that word?

          1. If it takes legislative action, then yes, it's a strategy. I see no reason to pretend that passing affirmative laws is a higher calling than repealing bad ones.

  7. One party supports something and then changes their stance when the other party adopts the position, and the process can repeat itself over and over again?

    Both parties are devoid of any principles other than doing whatever it takes to get votes?


    Next you're going to tell me that the sky is blue and that water is wet!

    1. It won't be truly "doing whatever it takes" until the fistfights occur during live Congressional hearings.

      I'm still in favor of the Klingon method of advancement. We would have a lean, corruption-free government with that.

      1. "In our religion you keep what you kill."

        Not Klingon, but it was the first thing that came to mind.

        1. That works, too.

  8. I mean, how can Peter note that "The good news is that utilization of these plans, which have only been around for about a decade, has been expanding rapidly," and yet claim that they are spreading "not by ObamaCare or other government-driven reforms, but by consumer preference and private sector innovation?" when, after all, HSAs were created in 2003 and require pairing with a high deductible plan?

    It certainly seems like that's a government thumb on the scale encouraging CDHP. It may be, as Peter has argued, a good overall policy, but it's not one that was done entirely through the private sector.

    It seems to me to be a curious omission.

    1. not one that was done entirely through the private sector.

      They werent done entirely thru the private sector because the public sector banned them.

      Removing a ban (even if only under certain conditions) isnt a sign of the public sector doing something.

      1. When you stop kicking your victim, you arent helping him.

        1. Sure you are. Inaction is action. Not doing something is a positive action.

          A really smart commenter told me so.

        2. Repealing a bad law is action. Your attitude is curious. Especially curious when the bad laws were passed by others, but curious nonetheless.

          You have internalized statist reasoning.

        3. And in any case, that certainly wouldn't apply to HSAs anyway. The law did much more than repealing a ban. I thought by that comment you were referring to bans on interstate purchase.

          You appear to be claiming that, by definition, ending the Drug War can never be a political strategy. I think that leads to a remarkable bias in favor of government "doing something."

      2. They definitely didn't have the special tax treatment for HSAs, which you only get when paired with a high deductible plan. It was a lot more than reducing a band in the 2003 law. It created HSAs, and strongly encouraged high deductible plans.

        I am confused by your claim that in general repealing bad laws isn't a political strategy or activity. That is an underlying attitude responsible for bias towards statism among both voters and politicians.

  9. Why should anyone really give a crap, other than when deciding how to vote in November IF their Senator was one who supported something they oppose?

    It's either a good idea or not. Democrats filibustered the Civil Rights Act, got the US into WW I for no reason whatever, started the Vietnam War, supported slavery, etc. Republicans were responsible for Watergate, suspended habeas corpus, introduced and enacted Smoot-Hawley, concocted the Spanish-American War, etc.

    What some think tank and some Senators did 20 years ago has no bearing whatever on whether something is a good idea, a bad idea, constitutional or not.

    History is important, and I'm not suggesting that nobody should write about it. It doesn't, however, constitute and argument for or against anything, in this case.

  10. Fast and furious has now been sealed:

    1. This should be fascinating to watch unfold now.

    2. Hold Holder in contempt. Even if Obama ignores it, the next administration can go after his ass for it.

      1. screw that. Impeach him. they can do that can't they?

    3. I love how they can't turn these documents over to Congress because of on going criminal investigations. But leaking that we had a double agent in Al Quada and were the ones behind Stuxnet to the New York Times was perfectly okay.

      1. Hey those made him look like a badass. Ya know 'cause havin' a kill list is cool.

    4. Yay. Let's play Watergate! Jesus, way to hand your opponents a stick to beat you with all the way through November.

      Why on Earth would you pick the only course of action that could elevate this issue to the point where it could play a role in maintaining office? Nobody was ever going to impeach Obama over signing off on it.

      1. But signing off on "it" was agreeing to flood Mexico with guns for the sole purpose of using it as justification of gun control here. They might not have gotten him impeached. But it would not have helped his re-election chances. And they are so arrogant they figure the media will just ignore this and the public will never hold him accountable for sealing the documents.

        1. And this is helping his election chances? Having CNN report on it every day? (Okay, CNN reporting on it affects no one, but insert your cable news station here.) They should have taken their lumps, but Holder out to pasture and moved on.

          You and I agree that it was all kinds of fucked up, but we aren't even remotely close to the average swing voter. "Mistakes were made, people were disciplined" would be fine at this point.

          1. The fact that they didn't release everything and go with the "mistakes were made" excuse tells me that the "mistakes" were not the usual kind and went right up to the President. These people are total amateurs. It would be just like them to brief Obama on this and destroy his positive deniability. Remember, Nixon was smart, Obama isn't.

            1. Just add some Illuminati or Bilderberg bullshit to it, John.

              Its not soup yet.

            2. You and I can definitely agree that these guys can't hit in the big-leagues. And I can see where the Chief of Staff was amateur enough to let this come up in a cabinet meeting and have positive remarks on record by the President. For all the Rahm Emanuel worship, I've always thought he was a terrible CoS. The agenda the Administration pursued and the manner in which they pursued it was shockingly bad under Rahm, and little improved under Daley. And that is ALL the Chief of Staff.

              1. Yeah, a real CoS could hide CIA agent outings and firing US attorney's for prosecuting party members.

                1. As opposed to leaking the identity of an active double agent and the details of covert efforts against Iran. Take your retarded talking points elsewhere shreek. And tell your loser masters at Balloon Juice we want a more intelligent troll.

                  1. No need to add Bilderbergers or Illuminati to it, shrike. What's there and who's involved, already, exist in real life and are even worse than imaginary bugaboos.

    5. Bush told Congress to go fuck themselves six time with EP on more serious issues. Obama is a mere piker.

      1. Congrats, yours is the first partisan team response I've come across so far.

        For everyone, do you think this is how the Obama-favoring media will spin this?

        1. They will just ignore it. There is no way to spin it. Shreek gets its troll talking points from the lefty websites that send him here. But that is just the internet. The major media just won't report on it or if they do spin it as the usual Washington partisan bickering.

          1. Yeah, I think that's a good prediction. They'll present it as partisan gamesmanship with Issa having a bizarre ax to grind.

            1. The liberals on slate are claiming this is okay because Issa refused to drop the contempt citation before getting the documents. So Issa was supposed to drop the contempt citation before he saw the documents and could make any determination if they were full responsive.

              Yeah, they are that dishonest and stupid.

        2. "Still more transparent than Clinton and Bush."

        3. For everyone, do you think this is how the Obama-favoring media will spin this?

          Of course not. It's just Bush's fault.

      2. Well it is a good thing you were so supportive of Bush when he did that. Otherwise your usual cock sucking of Obama on this might be seen as hypocritical or something.

        And DOJ selling thousands of guns to Mexican drug gangs in order to score cheap political points for gun control is a pretty big issue.

        1. Its a nutty conspiracy theory.

          1. Needs more talking points. That is exactly what happened here. They had no way to track the guns, they let them across the boarder and never told the Mexicans. And they let a WAPO reporting team in to report on the on going efforts to stop the flood of guns to Mexico. They repeatedly lied to Congress about it. And now are refusing to turn over documents.

            It is the worst government misconduct since Watergate. No amount of lying and repeating of your daily talking points will change that.

            1. Its about 1/10,000 of Iran/Contra.

              Now THAT was a scandal!

              1. How many Americans died because of Iran/Contra?

                1. Notice shrike never talks about anything but Republican-caused shit. True-Blue to the core, he is.

          2. Shocking... you just hit talking point number five.

            1. He comes here every day with a new set. He really is a professional troll. Note yesterday he started with the "you are just a old white guy and that is all that don't support the Dems" talking point.

              1. I'm aware... I am an infrequent poster, and a very frequent lurker. I had someone link that article to me just a couple of minutes before seeing one of the exact points being used.

                Being easily amused, I posted and linked it.

                1. Liberals are very good followers.

  11. http://www.dailymail.co.uk/new.....z1yK7gbr7D

    UK NHS kills nearly 130,000 elderly patients a year. Yes, liberals are here to kill you. They are not nice people.

    1. How many does Medicare kill here? It's the same shit.

      1. I'm not sure you're helping your cause, here.

        1. What is my cause?

          I am steadfastly anti-Medicare. I am for $50 co-payments to restrict its use for starters.

          1. HAHAHAHA POOP DICK!!!

          2. I am steadfastly anti-Medicare. I am for $50 co-payments to restrict its use for starters.

            AHAHAHAHHA Oh the irony.

            1. The irony of a stalwart Goldwater fan voting straight-ticket Democrat, as well.

    2. I only needed one bit of evidence to judge the NHS:

      A British soldier serving in Iraq died after a hospital transplant gave him a pair of lungs donated by a heavy smoker, a coroner has heard.


      A spokeswoman for Papworth, the UK's leading cardiothoracic hospital, said that it was not unusual to use smokers' lungs, adding that all organs are "screened rigorously" before a transplant. "We have a strong record of high quality outcomes and this is an extremely rare case."

      In the past year there were 146 lung transplants in the UK, and 84 people died while waiting on the transplant list, she added. "If we had a policy saying we did not use the lungs of those who smoked, then the number of lung transplants would have been significantly lower."


  12. As long as a large majority of Americans want

    (a) oodles of expensive health care, and
    (b) someone else to pay for it,

    there is no viable solution. The Donkeys and Elephants are just arguing over the particulars of the theft.

  13. Peter S: Close the facebook tab, edit and rewrite this post.

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