Absurdly, a central issue in the Republican presidential primary campaign is not so much the “individual mandate” for health care as which candidates once supported it.
Individual mandates are a requirement that every person carry health insurance -- self-paid, paid by an employer or paid by the government -- and there is nothing heinous about them. What this dispute illustrates is the unflagging opposition that Republican politicians have for President Barack Obama, whose health-care plan features an individual mandate.
Individual mandates were a Republican idea. They bubbled out of the conservative Heritage Foundation in the late 1980s and were adopted by many Republicans -- including Newt Gingrich -- as an answer to a plan advanced by the Clinton administration (and known as Hillarycare because then-first lady Hillary Clinton was in charge of producing it). Back then, in the early 1990s, Hillarycare was tarred as socialized medicine (it wasn’t) while individual mandates were presented as the free-market alternative.
Individual mandates are, in fact, the only practical alternative to a “single payer” (i.e., government-run) health-care system. That’s why Republicans supported them back in the Hillarycare days, and why we support them now. Without individual mandates, private insurance can’t possibly work. Why? Unless they are required to do so, young and healthy people won’t buy insurance until they need it. This leads to “adverse selection”: a vicious circle in which healthy people leave the pool, so those remaining are sicker than average and therefore cost more than average, rates go up, more people leave the pool, and so on.
None of this is to say that individual mandates will work. You can buy health insurance only if someone is willing to sell it to you at a price you can afford. A necessary corollary of individual mandates, therefore, is a requirement -- also part of the new law -- that insurers not discriminate on the basis of a “pre-existing condition.” But requiring coverage is not the same as requiring coverage at a price.
Republicans, however, aren’t arguing the pros and cons of an individual mandate (although that would be more useful). At the candidates’ debate Dec. 10 in Des Moines, it was all about who supported what and when. Governor Rick Perry of Texas repeatedly accused former Governor Mitt Romney of Massachusetts of supporting an individual mandate. He said to Romney, “The fact of the matter is, you’re for the individual mandate.”
Of course he’s not. None of those Republicans on that stage -- least of all Romney, with his legendarily flexible views -- has a secret hankering for individual mandates, now that they’ve become a hot potato. Under any of the Republican candidates, the U.S. would be safe from the individual mandate peril for at least four years. The issue has become the character of the candidates. Especially in this day of easy Googling, it’s pretty brazen to claim to have held a certain view on an issue when you actually held the opposite.
Two of the Republican candidates -- Romney and Gingrich -- stand accused of having supported individual mandates. Romney, as governor, campaigned for and signed a bill that included individual mandates. Subsequently -- no doubt never dreaming that this would become a huge campaign liability -- he urged other states to follow the Massachusetts example. (He says he wasn’t urging the Massachusetts model, including mandates, on them; he was just urging them to experiment. Clearly not true.) Gingrich, in Congress and after, supported the Heritage Foundation model as a free-market alternative to Hillarycare.
Nonsense and Bromides
Romney’s defense is that (a) the Massachusetts law only affected the 8 percent of the population who didn’t have health insurance, and left the 92 percent who did unaffected; and (b) he believes that health-care policy should be up to the states and has always opposed a federal mandate. The first argument is nonsense and doesn’t distinguish the Massachusetts plan from Obama’s at all. In fact, his contention that it does is an insult to the intelligence of the voters. Only people without insurance have to certify that they have insurance? Please. The Massachusetts law requires everybody to certify that he or she carries insurance, and imposes a stiff fine (just like Obama’s plan) on those who can’t or won’t certify that they are insured.
As for the second point, other than offering some bromides about how states are different from one another, Romney has never explained why a state-imposed mandate is OK with him but a federal mandate is not. In fact, Romney -- having flipped on this issue -- characteristically goes to the opposite extreme: A federal mandate is not merely impermissible, but would be a disaster and must be repealed ASAP. Is there something about the people of Massachusetts that makes providing health care for them fundamentally different from providing it for the people of, say, New Hampshire? Romney’s rationale reeks of ex-post-facto.
Gingrich’s defense is somewhat better. He said in the Dec. 10 debate that it all goes back to Hillarycare. “Virtually every conservative saw the mandate as a less dangerous future than what Hillary was trying to do. … I frankly was floundering,” he said, grabbing onto the Heritage plan as a life buoy. Only after the Clinton plan was defeated did he start to discover problems with mandates, including the problem that they are “clearly unconstitutional.”
The chronology is a bit suspicious -- as recently as May Gingrich was supporting something that sounded a lot like a mandate, and he didn’t turn decisively against them until it became clear they were political poison. The Supreme Court will soon give us an answer to the constitutional question. But one reason we’re skeptical about the argument that the individual mandate for health care is unconstitutional is the way this radical re-interpretation of the Constitution became “clear” to so many conservatives so suddenly.
To repeat: This dispute is not about health care. It is about character and honesty. Perry is merely missing the point. Gingrich is at best disingenuous. Romney, meanwhile, is in two-plus-two-equals-five territory.
To contact the Bloomberg View editorial board: firstname.lastname@example.org.