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The Individual Mandate's Conservative Origins

[ Posted Wednesday, March 28th, 2012 – 16:37 PDT ]

For the past three days, the political world has been largely focused on the Supreme Court, and the arguments over whether President Obama's signature legislative achievement is constitutional or not. At the heart of the argument is the "individual mandate," a section of the law which would require Americans to pay more money on their income taxes if they could afford health insurance but chose not to purchase it from a private company.

In the 2008 presidential election campaign, Barack Obama disagreed with Hillary Clinton on this issue. Clinton was for the individual mandate, Obama was not. Once he got elected and started wheeling and dealing with the insurance industry, however, Obama agreed to include the individual mandate in the law now universally known as "Obamacare."

While we're all waiting for the verdict from the Supreme Court, I thought it would be worthwhile to dig into the actual origins of the concept of the individual mandate. Now, the idea itself may have been around for much longer than the documentation I could find online, but the real political push behind the idea seems to have started in 1989, from the ultra-conservative Heritage Foundation.

Stuart M. Butler, who at the time was Heritage's Director of Domestic Policy Strategies, wrote the second chapter of a position paper with the title A National Health System for America. [Heritage has a PDF version of this document you can download from their website.] The document was over 100 pages long, and envisioned a "consumer-oriented, market-based, comprehensive American health system" that would become "the model for the entire industrialized world." It was a strictly conservative plan, as evidenced by the inclusion of the idea of replacing Medicare with a voucher system (the same thing Paul Ryan is now championing, in other words).

In his chapter "A Framework for Reform," Butler lists three elements which would be required to remold the American health care system into his conservative vision for the future. The very first of these, in full (chapters referenced are from the same document):

Element #1: Every resident of the U.S. must, by law, be enrolled in an adequate health care plan to cover major health care costs.

This requirement would imply a compact between the U.S. government and its citizens: in return for the government's accepting an obligation to devise a market-based system guaranteeing access to care and protecting all families from financial distress due to the cost of an illness, each individual must agree to obtain a minimum level of protection. This means that, while government would take on the obligation to find ways of guaranteeing care for those Americans unable to obtain protection in the market, perhaps because of chronic health problems or lack of income, Americans with sufficient means would no longer be able to be "free riders" on society by avoiding sensible health insurance expenditures and relying on others to pay for care in an emergency or in retirement.

Under this arrangement, all households would be required to protect themselves from major medical costs by purchasing health insurance or enrolling in a prepaid health plan. The degree of financial protection can be debated, but the principle of mandatory family protection is central to a universal health care system in America.

Help would be provided in two ways. First, the tax code would be amended, as Chapter 3 describes, to give tax relief to individual purchasers of health insurance or prepaid plans and to provide tax credits for out-of-pocket expenses. Second, government would aid those who, because of income or medical condition, find the cost of protection to be an unreasonable burden. Such aid could take the form of vouchers for purchasing insurance or state-managed systems as described in Chapter 5.

The requirement to obtain basic insurance would have to be enforced. The easiest way to monitor compliance might be for households to furnish proof of insurance when they file their tax returns. If a family were to cancel its insurance, the insurer would be required to notify the government. If the family did not enroll in another plan before the first insurance coverage lapsed and did not provide evidence of financial problems, a fine might be imposed.

In the mid-1990s, of course, the Democrats attempted health care reform. The most famous of these attempts was Hillary Clinton's, but many other Democrats also proposed plans of their own in Congress. By 1994, Butler (now listed as "Vice President and Director of Domestic Policy Studies" at Heritage) wrote a critique of the individual mandate included in one of these Democratic bills, although it's interesting to note that he doesn't seem to be against the concept itself, rather choosing to complain about the projected costs to families of the plan. Constitutional questions aren't even raised.

By 2003, congressional Democrats had failed in their health reform efforts (and Obama's election was still five years in the future), so it was safe once again for conservatives to back the individual mandate. At this point in time, Butler's title at Heritage was "Vice President of Domestic and Economic Policy Studies," and he was testifying before the Senate Special Committee on Aging. Here, however, he specifically points out at the beginning of his testimony that the views he is expressing are his own and not the official position of the Heritage Foundation. During his testimony, Butler gives even more detail on how he sees the individual mandate working:

The current social contract should be replaced with a more rational one. In a civilized and rich country like the United States, it is reasonable for society to accept an obligation to ensure that all residents have affordable access to at least basic health care -- much as we accept the same obligation to assure a reasonable level of housing, education and nutrition.

But as part of that contract, it is also reasonable to expect residents of the society who can do so to contribute an appropriate amount to their own health care. This translates into a requirement on individuals to enroll themselves and their dependents in at least a basic health plan -- one that at the minimum should protect the rest of society from large and unexpected medical costs incurred by the family. And as any social contract, there would also be an obligation on society. To the extent that the family cannot reasonably afford reasonable basic coverage, the rest of society, via government, should take responsibility for financing that minimum coverage.

The obligations on individuals does not have to be a "hard" mandate, in the sense that failure to obtain coverage would be illegal. It could be a "soft" mandate, meaning that failure to obtain coverage could result in the loss of tax benefits and other government entitlements. In addition, if federal tax benefits or other assistance accompanied the requirement, states and localities could receive the value of the assistance forgone by the person failing to obtain coverage, in order to compensate providers who deliver services to the uninsured family.

The individual mandate which was included in Obamacare is so close to what Stuart Butler of the Heritage Foundation initially suggested that we can honestly say there is no appreciable difference between the two. The only real difference is whether Republicans supported the idea or not. When it was branded as a conservative idea from a conservative think tank, then Republicans embraced the idea as requiring "personal responsibility" from all those deadbeats out there who were getting a free ride on the taxpayer's dime. These were the days when "reforming welfare" was a big deal, and Republicans tended to lump a lot of things under the dreaded "welfare" label, to give some rhetorical context.

But when Democrats agreed to the idea -- in the 1990s, and then later when Obamacare was being debated -- Republicans decried the idea and refused to support it (to put all their histrionics and hyperventilating over Obamacare's mandate in the mildest terms I can manage). That, it seems, is really the only thing which has changed over time. The idea itself hasn't changed in any appreciable way from what was proposed in 1989. Republicans' support of the idea, however, waxes and wanes depending on who proposes it.

Well, to be fair, I should say "those Republicans who are not named Mitt Romney," as Mitt is truly in a class by himself when it comes to supporting... and then not supporting... the idea of the individual mandate. But that's a subject for an entirely different column.

-- Chris Weigant

 

Cross-posted at Business Insider
Cross-posted at The Huffington Post

Follow Chris on Twitter: @ChrisWeigant

 

30 Comments on “The Individual Mandate's Conservative Origins”

  1. [1] 
    Michale wrote:

    It's fair to say that Republicans changed their mind on supporting the Mandate..

    From 1989 until today...

    You really can't fault the GOP for that. Especially when you consider that Obama ALSO changed his mind..

    But from 2008 to 2009....

    One smacks of careful consideration of an issue and coming to the conclusion that that WRONG decision was initially made..

    The other smacks of political expediency upon realization of a B.B.D....

    I'll leave ya'all to figure out which is which...

    Michale....

  2. [2] 
    Michale wrote:

    One smacks of careful consideration of an issue and coming to the conclusion that that WRONG decision was initially made..

    OK, I have to admit.. I had to laugh at myself and say, "sheeya right".... :D

    But still.. Changing one's position from 1989 to present is NOTHING compared to changing one's position from 2008 to 2009...

    Michale......

  3. [3] 
    Chris Weigant wrote:

    Michale -

    Changing position in 2009 (which both Romney and Obama did, I hasten to point out) is political opportunism.

    Changing position from "yea" in 1989, then to "nay" in 1994, then to "yea" in 2003, then to "nay" in 2009... is nothing short of the sheerest hypocrisy. "I'll support it if my guys support it, but if the other guys support it, I'm against it" is intellectually null and void.

    -CW

  4. [4] 
    Elizabeth Miller wrote:

    Chris,

    Clinton was for the individual mandate, Obama was not. Once he got elected and started wheeling and dealing with the insurance industry, however, Obama agreed to include the individual mandate in the law now universally known as "Obamacare."

    ...wheeling and dealing with the insurance industry?

    Is that the totality of what and who Obama dealt with on arriving at the necessity of a mandate?

  5. [5] 
    nypoet22 wrote:

    Changing position in 2009 (which both Romney and Obama did, I hasten to point out) is political opportunism.

    Changing position from "yea" in 1989, then to "nay" in 1994, then to "yea" in 2003, then to "nay" in 2009... is nothing short of the sheerest hypocrisy.

    michale,

    i believe my students would say you just got "Pwned!" of course, it supports your general thesis that both sides are essentially corrupt and malleable.

    ;)

  6. [6] 
    Elizabeth Miller wrote:

    Joshua,

    Do you teach your students that "both sides are essentially corrupt and malleable"?

  7. [7] 
    Elizabeth Miller wrote:

    Joshua,

    Please disregard that reply as I completely misread your comment.

    It's all Michale's fault, I can assure you.

  8. [8] 
    Chris Weigant wrote:

    nypoet22 -

    I hasten to point out that Romney flipped from supporting it (he even wrote a USA Today editorial telling Obama to use MA's Romneycare as a national model) in 2009, to not supporting it (once he saw which way the political winds were blowing in his own party).

    Obama, on the other hand, flipped the other way. Maybe it's one of those Zen things, where everything in the Universe balances out... heh.

    Liz -

    Depends on whose story you believe. Chris1962 is fond of pointing this one out, so I'll give her a chance to post a link, if she's tuned in.

    Single-payer was (by some reports) traded away at the very beginning of the process in an agreement between Obama (or "the White House" at the very least) and the insurance company execs.

    I'm not sure I buy the totality of the argument, but in its behalf I have to say it does have a certain plausibility...

    ...and I have to say, on a personal note, good to see you back! I haven't had an enormous amount of time for answering comments of late, but I've missed your pithy quips, I must admit.

    :-)

    -CW

  9. [9] 
    Chris Weigant wrote:

    Oh, and since I'm lazy, I'm posting the full SCOTUS/SCOCW.com bet here for posterity.

    Bet is between David (akadjian) and Michale, and (kind of) me.

    If The Nine declare the mandate unconstitutional, David must wear this shirt for a day.

    If the Supremes declare Obamacare hunky-dory, Constitution-wise, Michale has to wear this shirt (tank top specified and agreed to) for a day.

    If SCOTUS decides AIA applies, and they won't accept the case before 2105 (at the earliest), then I will wear an equally-odious (to me) shirt (NOBODY can find an "I love Brian Williams" shirt?!? Or maybe a Bill O'Reilly "No-spin zone" shirt???) for a day.

    [Aside: I would have chosen a different shirt for Michale, the one that says "{photo of Osama} = dead / {GM logo} = alive / {Obama campaign logo "O"} = 2012" but I didn't want to influence the wagering...]

    Shirt must be worn for maximum embarrassment among friends, work buddies, colleagues, and customers, for a full day. As public as possible, whether weekday or weekend, with maximum interaction with other folks.

    Here's the kicker I added: For the whole day the loser is not allowed to answer the question "Why the heck are you wearing that piece of garbage?!?" or other related inquiries -- not even with the generic "I lost a bet" -- and cannot explain himself in any way to anyone who asks until the following day. The only allowable response: "Ask me again tomorrow. I'm sorry, that's all I can say."

    Heh.

    Gentlemen? Are we agreed?

    This may be the first non-Quatloo bet here, a historic occasion indeed...

    -CW

  10. [10] 
    Elizabeth Miller wrote:

    Chris,

    Depends on whose story you believe. Chris1962 is fond of pointing this one out, so I'll give her a chance to post a link, if she's tuned in.

    She can keep her links to herself. And, I mean that sincerely. I'm not trying to be facetious here.

  11. [11] 
    Elizabeth Miller wrote:

    Chris,

    As far as I understand, "single-payer" was never in the cards to be "traded away" - before, during or after Obama's run for the presidency. Most of y'all despise single-payer if I know anything about public opinion polls. I don't see that changing anytime soon with all of the disinformation flying around out there, coming from all directions.

    And, if the comments over at HP are any indication, there isn't a great deal of understanding about what the individual mandate is all about, either.

    I'd bet the farm - even if it's in Iowa - that most people don't make the essential connections between the critical need for healthcare reform, the capacity for economic growth, and why the Obama administration put so much time and effort into crafting legislation that would begin to move forward on this overarching issue during the height of the most destructive financial crisis since the Great Depression.

  12. [12] 
    Elizabeth Miller wrote:

    Oh, and ... pithy quips!?

    I'll have you know that I resemble that remark.

    :)

  13. [13] 
    Elizabeth Miller wrote:

    If the Supremes declare Obamacare hunky-dory, Constitution-wise, Michale has to wear this shirt (tank top specified and agreed to) for a day.

    I think that tank would look fantastic on Michale, win or lose, but there should be a coresponding quote from Biden on the back ... something along the lines of "... nothing more audacious in at least 500 years! ... the VEEP

    Heh.

  14. [14] 
    Elizabeth Miller wrote:

    Michale,

    I think Chris forgot something ...

    If the Supremes declare Obamacare hunky-dory - which, after all, is their only conceivable and viable option, all things considered - then you must also agree to toss crapcare into the, well, you know ...

    Wear your Obama/Biden tank proudly!

  15. [15] 
    Chris Weigant wrote:

    Liz [11] -

    I'd give a freakin' arm and a leg for single-payer, and there are many Americans who feel the same way. I've seen health care in France, and it was cheap, efficient, and universal. Nobody ever went bankrupt because of their health, and that's a good thing!

    Well, on second thought, perhaps a better metaphor would have been more in order. So be it. Heh. [Note to Michale and Chris1962: here's a good opening for a cheap shot! Cue up the "arm and a leg" jokes!]

    Seriously, though, you are right. Single-payer never had a chance. The public option, maybe, but never single-payer. But it would surely have been nice if the single-payer advocates had had a chance to make their case in the congressional record. I will never forgive Max Baucus for denying them this chance -- and having doctors willing to make this case hauled out of his hearing room by the cops when they tried to. Grrr.

    That's all they were really asking for -- knowing full well they didn't stand a chance politically -- to make their case to the American public, in the hopes that in the future their testimony would resonate. And they didn't even get that chance. Due to a so-called "Democrat."

    Grrr. It still chafes, if truth be known. Even more than the "Cornhusker Kickback" this is what sticks in my craw about the entire HCR debate.

    What always astonished me was why the might of American business (the US Chamber of Commerce, for instance) didn't get behind the idea. Think about it: they could forever dump off their responsibility to provide healthcare to their workers on the federal government (complete with all of the headaches that implies), and cut their costs to boot. What's not to love for a bottom-line-myopic businessman to love?

    [12] -

    Hey, "pithy quips" is a compliment, around here!

    :-)

    [13] -

    Well, I wasn't going to bring that particular Bidenism up, so as not to discomfit you. Heh.

    [14] -

    Oooh! Now there's a gauntlet if I ever saw one tossed down... Michale, whaddya say? If SCOTUS rules it's officially hunky-dory, will you retire "CrapCare" forever?

    After all, even the Obama campaign has embraced "Obamacare" at this point...

    Heh.

    -CW

  16. [16] 
    Michale wrote:

    CW,

    Changing position in 2009 (which both Romney and Obama did, I hasten to point out) is political opportunism.

    Changing position from "yea" in 1989, then to "nay" in 1994, then to "yea" in 2003, then to "nay" in 2009... is nothing short of the sheerest hypocrisy. "I'll support it if my guys support it, but if the other guys support it, I'm against it" is intellectually null and void.

    No argument from me there...

    Which simply goes along with what I have always said.

    It doesn't matter whether a politician is a Democrat or a Republican..

    They BOTH suck...

    Joshua,

    i believe my students would say you just got "Pwned!" of course, it supports your general thesis that both sides are essentially corrupt and malleable.

    Yep, pretty much... :D

    Liz,

    It's all Michale's fault, I can assure you.

    hehehehehehehehehehehe :D

    I'd bet the farm - even if it's in Iowa

    Not Kirk's farm!!!! :D

    Oh, and ... pithy quips!?

    Would that be pithy quips??? Or quithy pips??? :D

    CW,

    Regarding {9} that sounds great to me.. :D

    I'll even go one better, although I would not expect that David could reciprocate.

    I will provide a link if that fateful day ever comes to pass, where Weigantians can log in and watch me at my shop STREAMING LIVE for the day of the shirt wearing...

    That way, it can be verified that I am, indeed, in full Obama regalia... :D

    Liz,

    If the Supremes declare Obamacare hunky-dory - which, after all, is their only conceivable and viable option, all things considered - then you must also agree to toss crapcare into the, well, you know ...

    Actually, you may have noticed in the commentaries since David and I agreed on the bet, I have been referring to it as "ObamaCare"..

    Regardless, I will accept your stipulation. If SCOTUS rules for Obama over the Mandate, I will forever retire the term "CrapCare" and it will forever be called "ObamaCare" by yours truly..

    Although not a requirement, if SCOTUS rules that the Mandate is unconstitutional, I would like to see CrapCare adopted as the official CW.COM designation...

    Like I said, not a requirement, just something that would be nice. :D

    Michale.....

  17. [17] 
    Michale wrote:

    Wow, talk about timing!!!

    CW
    [ Thursday, March 29th, 2012 at 03:07 PDT ]

    Michale
    [ Thursday, March 29th, 2012 at 03:08 PDT ]

    :D

    Michale.....

  18. [18] 
    Michale wrote:

    CW,

    Oooh! Now there's a gauntlet if I ever saw one tossed down... Michale, whaddya say? If SCOTUS rules it's officially hunky-dory, will you retire "CrapCare" forever?

    I will...

    How about my idea?? If the SCOTUS rules the Mandate unconstitutional, will "CrapCare" become the official CW.COM designation?? :D

    Michale.....

  19. [19] 
    akadjian wrote:

    For the whole day the loser is not allowed to answer the question "Why the heck are you wearing that piece of garbage?!?"

    You play hardball, CW ... but I'm in :). Nice stipulation. This will make getting pictures more difficult, but I think it can still be done.

    I'd give a freakin' arm and a leg for single-payer, and there are many Americans who feel the same way. I've seen health care in France, and it was cheap, efficient, and universal.

    Me too! It works so much better and is so much more cost effective.

    The trouble is that it would end some very large companies who are willing to put up a lot of money to make sure it never happens.

    -David

  20. [20] 
    Michale wrote:

    http://p.washingtontimes.com/news/2012/mar/28/bowles-simpson-goes-down-defeat/

    What IS it about Obama's Budgets that can't garner a SINGLE vote ANYWHERE???

    Michale....

  21. [21] 
    dsws wrote:

    The obligations on individuals does not have to be a "hard" mandate, in the sense that failure to obtain coverage would be illegal. It could be a "soft" mandate, meaning that failure to obtain coverage could result in the loss of tax benefits

    Anyone think The Nine (or should I say The Five, since four votes don't count for much on a consistently 5-4 Court) will throw out the "soft mandate" to buy a house, aka the mortgage interest deduction?

  22. [22] 
    Michale wrote:

    What's REALLY going to kill the Obama Administration is if the SCOTUS ruling is 7-2 Against....

    No amount of spin from the Left will help THAT particular plane wreck....

    Considering the kinds of questions Sotomayer asked, it's not outside the realm of possibility...

    Michale......

  23. [23] 
    Michale wrote:

    What's REALLY going to kill the Obama Administration is if the SCOTUS ruling is 7-2 Against....

    That should read:

    What's REALLY going to kill the Obama Administration is if the SCOTUS ruling is 6-3 Against....

    My bust

    Michale.....

  24. [24] 
    Paula wrote:

    Chris:
    "I'd give a freakin' arm and a leg for single-payer, and there are many Americans who feel the same way."

    Yep, yeppity, yep.

    That single payer was shut out by democrats still enrages me. Yeah, yeah, it was a long shot but it never got its day in court. Furthermore, while many people in this country tended to shy away from it, when poll questions were worded that discussed the benefits of a single-payer system, or when people were asked if they were in favor of Medicare for All, approval shot up. The public has been lied to for years in this country when it comes to S.P. It's been a deliberate misinformation campaign to keep people from even remotely considering the option.

    The public option was a compromise that should have been included. The thing about the mandate that I don't like is that I absolutely despise the thought of putting a dime in the coffers of a medical insurance company. I think their behaviors were despicable and unforgivable. I understand the need to pay for coverage in one form or another but I really loathe the notion that I MUST deal with one of these companies. I want a "conscientious objection" option.

    Separately, re the fate of the mandate or any of the ACA - this week certainly sealed forever my view that Scalia is a scourge, a smelly pustule on the body politic and a sanctimonious prick. He was literally doing FOX/Rightwing talking points - not only does he use stupid and contradictory arguments, he preens himself on his brilliance. Allegedly he is quite intelligent. If so his brains have been overtaken by his idealogy. (While I'm ranting, lets not forget all the go-along to get-along Dems that gave G. Bush the benefit of the doubt when he picked his judges. Thanks guys.)

    Bush v. Gore and now this. When that man uses any words about activist judges, not to mention, strict construction, precedent, or even principles, its a wonder his tongue doesn't stuff itself down his throat and strangle him.

  25. [25] 
    Michale wrote:

    Separately, re the fate of the mandate or any of the ACA - this week certainly sealed forever my view that Scalia is a scourge, a smelly pustule on the body politic and a sanctimonious prick. He was literally doing FOX/Rightwing talking points - not only does he use stupid and contradictory arguments, he preens himself on his brilliance. Allegedly he is quite intelligent. If so his brains have been overtaken by his idealogy. (While I'm ranting, lets not forget all the go-along to get-along Dems that gave G. Bush the benefit of the doubt when he picked his judges. Thanks guys.)

    Bush v. Gore and now this. When that man uses any words about activist judges, not to mention, strict construction, precedent, or even principles, its a wonder his tongue doesn't stuff itself down his throat and strangle him.

    Of course, there is a MUCH a simpler explanation...

    He's right and your wrong...

    But I can understand why you wouldn't want to even CONSIDER that argument.. :D

    Michale.....

  26. [26] 
    akadjian wrote:

    The thing about the mandate that I don't like is that I absolutely despise the thought of putting a dime in the coffers of a medical insurance company.

    Well said, Paula. And I think if you asked, a lot of people would echo these comments. It's why I really hated the bait and switch that happened.

    While I do think there's much good which was included in the ACA, I have an awful hard time defending the mandate.

    It's just funny. Because conservatives got Democrats to pass a conservative plan and then turned on it just because Democrats passed it. And then Romney got run over by the health care bus, which again was a conservative plan. Once Democrats do something conservative apparently it can't be conservative anymore. Absolutely absurd ...

    I believe thought has almost completely stopped and been replaced by identity politics.

    -David

  27. [27] 
    Paula wrote:

    David:

    "I believe thought has almost completely stopped and been replaced by identity politics."

    Exactly. It would be funny if it wasn't so awful. It's so barefaced, so utterly hypocritical and without principle.

  28. [28] 
    Michale wrote:

    I believe thought has almost completely stopped and been replaced by identity politics.

    EXACTLY!!

    DING!! DING!! DING!!

    We have a winner..

    Even Paula is dead on ballz accurate........

    It's so barefaced, so utterly hypocritical and without principle.

    This is one of those patented handy-dandy CW.COM trueisms...

    It can be accurately applied to both Democrats and Republicans...

    Michale.....

  29. [29] 
    dsws wrote:

    I believe thought has almost completely stopped and been replaced by identity politics.

    I believe I must have missed the golden age of thoughtful non-identity politics. Was it before or after Machiavelli published? Singin' songs and carryin' signs was mostly saying 'hooray for our side' long before the song was written, let alone before now. "Nobody's right if everybody's wrong" applies well too.

  30. [30] 
    nypoet22 wrote:

    I believe thought has almost completely stopped and been replaced by identity politics.

    oh there's still thought, it's just a different kind of thought, and most people haven't realized it yet.

    "If you see the world in terms of Left & Right, you really aren’t seeing the world at all . . ."
    -barry ritholtz

    there are corporations and government on one side, and individuals on the other. every other conflict, left-right or otherwise, pretty much comes second.

    ~joshua

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