Probably no effort at political triangulation (what used to be called compromise) has failed the Obama Administration so badly as the individual health insurance mandate. There are ways, though, to get the steak without the political sizzle, provided Republicans choose to cooperate.
The reason for imposing an individual mandate on freedom-loving Americans was that Democrats want to transform the country into socialist hell. Ooops… that’s a secret we’re not supposed to share!
Let’s hypothesize instead that Congress and lobbyists for the insurance industry wanted to keep health insurance in the private sector, and that a mandate manages the problem of “free-riding” inherent to any system in which individuals or their employers buy their own coverage. For without a mandate imposed on those who can afford coverage, healthy people would have the option of waiting until they are sick to apply.
Seemed reasonable to Mitt Romney, when he engineered a mandate in the Massachusetts insurance system. And it was the lynchpin of the reform proposed by the influential, conservative (but not yet ultra-partisan) Heritage Foundation back in 1989. (Don’t try to find the smoking gun, though, on the Heritage website.) Ironically, candidate Obama opposed the mandate when he was trying to prove he was more centrist than Hillary Clinton. But he came around as president, in part because it was an easy fix to a hard problem, in part because the health insurance lobbies wanted it, in part because he thought conservatives would see it as an acceptable price to pay to keep the system private.
The rest, of course, is history. Republican strategists latched on to the mandate issue as a potential winner in a country in which everybody loves dessert and almost nobody is willing to eat their spinach first. Now, even if Obama and Congressional Democrats do well in the election and block any changes to the law, a very-well-insured majority on the Supreme Court might just decide that the mandate is unconstitutional.
So, what are the alternatives? One is muddling through: The (less) Affordable Care Act would remain the law of the land even if the mandate tanked, and Democrats certainly wouldn’t help to repeal it. Premiums would go up faster than otherwise. But at least more Americans would be spared financial ruin from catastrophic illness.
The other alternative is to amend the law to discourage free-riding in a way that passes muster with the Supremes — say, by charging a financial penalty to those who enter the system after an initial enrollment period. This, by the way, is how it’s done with the Medicare drug benefit engineered by the Bush Administration.
Of course, the Republicans could win big in the election and use their clout (mandate?) to repeal the health care law. Then it would be business-as-usual; the system would presumably limp along until the politics of spotty coverage and unchecked health care inflation seemed less attractive than the specter of Big Brother.
We can’t resist adding a last irony to this poisonous political brew, though. As Paul Starr points out in The New Republic, a Supreme Court decision barring the individual mandate would also apply to any future Republican initiative to privatize Medicare. Good luck with that, guys.
(This post was also published on Forbes.com.)