ANALYSIS: Republican field shies away from history on insurance mandate

Introduction

In the Republican presidential debate Tuesday night, former House Speaker Newt Gingrich acknowledged, apparently in an unguarded moment, that a core element of “ObamaCare,” the requirement that all Americans be enrolled in either a private or public health insurance plan, was a proposal originated by the Heritage Foundation, a powerful conservative think tank.

Gingrich made the admission as he was denying former Massachusetts Governor Mitt Romney’s accusation that the former Republican leader was once a supporter of the mandate.

I’m sure the other presidential hopefuls on the stage in Las Vegas were holding their breath, praying they would not be asked why they all are now so staunchly opposed to the very notion of such a mandate, which several GOP attorneys general are even alleging in various lawsuits violates the U.S. Constitution. As a result of those lawsuits, the Supreme Court is likely to rule next year on the constitutionality of the mandate and the entire reform law.

The candidates’ prayers were answered. Not one of them was asked why an idea conceived more than two decades ago by several conservative economists and favored by Republican lawmakers is a horrible idea now.

If they had been asked and had been honest in their responses, they undoubtedly would have said it is because Barack Obama is not a Republican and also because the mandate, according to almost every poll, is the least popular part of the Affordable Care Act.

The Heritage Foundation was not alone in advocating for an individual mandate, which was the cornerstone of its “Responsible National Health Insurance” plan back in 1991. It was also endorsed by one of the other preeminent conservative and pro-business think tanks, the American Enterprise Institute, which for many years received funding from one of the companies I worked for, CIGNA Corporation. (CIGNA endowed a chair at AEI to honor Wilson Taylor when he retired as chairman and CEO of the company.) You can rest assured that AEI would never have supported an individual mandate if insurance companies hated the idea.

Fast forward to 2009. The insurance industry was so determined to have an individual mandate included in the reform bills working their way through Congress that it sent a pro-mandate emissary to the White House several times to persuade President Obama to embrace the concept — which Obama had denounced. Obama said during the presidential campaign that he did not think Americans should be forced to buy something they couldn’t afford. But former Aetna CEO Ron Williams, who, according to visitor logs, made at least a half dozen trips to the White House after Obama was elected, carried the insurance industry’s message that a mandate coupled with subsidies from the government to help people pay for coverage would solve the problem of affordability.

Thus persuaded, the White House threw its weight behind the concept, and, of course, the bill Obama signed in May of last year included it. I can imagine that at least some mandate supporters also led the president to believe — or at least hope — that, since the mandate was originally a Republican idea, his reform proposal would win the support of enough GOP members of the House and Senate that he could claim bipartisan support for his legislation. No such luck.

The idea of the mandate dates back to 1989 when Stuart Butler and Edmund Haislmaier of the Heritage Foundation proposed it in an article entitled, A National Health System in America. The moniker Responsible National Health Insurance debuted two years later when economists Mark Pauly, Patricia Danzon, Paul Feldstein and attorney John Hoff expounded on the idea in an article published first by the Heritage Foundation and, in an expanded version, by AEI in 1992.

The GOP was so fond of the idea that Sen. John H. Chaffee of Rhode Island and several other Republicans introduced legislation during the 1993-94 debate on the Clinton health care plan to require individual households to obtain coverage for acute and emergency care. Out-of-pocket expenses could not exceed what each household could afford. The provisions of the Affordable Care Act pertaining to the mandate surely were modeled after Chaffee’s bill.

The proponents of the mandate said at the time that they felt it was necessary to deal with the growing problem of “free riding,” or uninsured people accessing health care but having no insurance or other means to pay for medical treatment once they had received it. They also proposed it as a “free-market” counter proposal to a single-payer system like Canada’s, which many Democrats supported (and still do).

AEI even dealt with the argument against the mandate we are hearing today: that it infringes on our freedom to remain uninsured if that’s what we want to do. AEI responded that society already interferes with individual freedoms by requiring Americans to contribute to the Social Security system.

So the next time you hear a Republican candidate denounce ObamaCare and the individual mandate around which it is built, know that it was an idea embraced by leading conservatives and GOP members of Congress not that long ago.