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updated 12/7/2007 5:29:39 PM ET 2007-12-07T22:29:39
Political connections

The heated argument over health care between Sens. Hillary Rodham Clinton and Barack Obama resembles a game of political Twister.

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Clinton is rhetorically criticizing Obama from the left over a policy dispute that substantively places her to his right. Clinton is lashing Obama for not offering a plan that provides health insurance to all Americans -- a perennial liberal priority. But the actual difference between their proposals is that Clinton, unlike Obama, would require every uninsured American to buy insurance -- an idea, known as an individual mandate, first championed by conservatives.

Most Republicans now deride the individual mandate as big-government meddling. But the idea once attracted extensive support from conservatives -- from iconic economist Milton Friedman to the Heritage Foundation -- both for philosophical (encouraging personal responsibility) and economic (reducing the cost-shifting that occurs when patients don't pay their bills) reasons. The late Sen. John Chafee, R-R.I., proposed an individual mandate in 1993. In 2004, Republican Mitt Romney, then Massachusetts' governor, endorsed the idea, beginning the process that led his state to approve a universal coverage plan in 2006.

Liberals have opposed the individual mandate most when it has been offered as an alternative to either government-funded care or a mandate on employers to insure their workers. But even when the individual mandate has been linked to both government subsidies and an employer mandate (as Clinton and former Sen. John Edwards have proposed), liberals sometimes have balked. They initially resisted that combination in Massachusetts (before finally accepting it) and are still resisting it in California, where GOP Gov. Arnold Schwarzenegger has built his universal coverage plan around such a twin mandate.

Although Republicans raise mostly ideological objections to an individual mandate, Democrats express more-concrete concerns. For liberals, notes Anthony Wright, a California health care advocate, the key issue is whether the government subsidies are sufficient to ensure that uninsured families can afford the coverage that a mandate compels them to buy. Notably, the Left didn't object when Bill and Hillary Clinton included a requirement that individuals contribute up to 20 percent of premium costs in their 1993 universal coverage proposal.

It is on this front that Hillary Clinton faces the toughest questions today. She responds to concerns about the mandate's affordability by noting that her plan (like Edwards's) would cap the share of income that individuals must contribute to premiums, with government subsidies covering the rest. But, wary of providing a target for opponents, her campaign won't say what that cap will be. Although Clinton has promised generous funding for the public subsidies, it's difficult to see how uninsured families can judge her proposal without knowing even roughly how much of their income it would require them to contribute to buying insurance.

Even so, in polling by the Harvard School of Public Health, nearly 80 percent of Democrats said they favored an individual mandate (while most Republicans opposed it). Robert Blendon, a professor at the health school, believes that is because Democrats are so eager to achieve universal coverage they will accept any means to get there.

That grassroots embrace of the mandate demonstrates a sound political instinct. Both the Massachusetts and California experiences show that the individual mandate can advance reform. It frames universal coverage as a shared responsibility between individuals, government (which provides subsidies to help families meet the mandate's cost), and employers (who must either insure their workers or pay fees that help fund the subsidies).

It's here that Obama faces his own contortions. He commendably calls for building a broad health care consensus that includes the insurance industry. But in the states, the individual mandate has been critical in persuading insurers to accept reform, including the requirement that they no longer reject applicants with pre-existing health problems, a key liberal goal. If such a requirement isn't tied to a mandate, insurers correctly note, the uninsured can wait until they are sick to buy coverage, which will inflate costs for everyone else. By seeking guaranteed access without an individual mandate, Obama is virtually ensuring war with the insurance companies that he has pledged to engage.

Obama is right that requiring families to buy insurance they can't afford is futile. But the answer is to ensure affordability rather than abandoning an individual mandate that could offer the best hope of untangling the stalemated politics of universal health care.

Copyright 2012 by National Journal Group Inc.

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