What flip flops on the individual mandate mean for Dems and Repubs

(a similar piece was posted on freeforall on March 19, 2012)

Governor Mitt Romney is just four years too late. If he had beaten Senator McCain for the 2008 Republican nomination, the individual mandate would  have been front and center in his campaign; a ‘make the trains run on time’ corporatist approach to pooling health insurance risk that could save the country from the wild-eyed liberal schemes that Senator Obama would surely impose, yada yada. I am sure Gov. Romney would have taken tremendous glee in saying something like this over and over: “even Hillary Clinton has embraced the individual mandate that we successfully implemented in Massachusetts; only Senator Obama remains committed to a government takeover of health care that was rejected when Hillarycare was defeated.”

Of course, the ACA (aka Obamacare) with the individual mandate front and center came to not only be called a government takeover, but an assault on liberty and freedom itself. The Supreme Court will have their say in a few days, but it is worth asking what do the flip flops on the individual mandate mean more broadly?

The President did attack the individual mandate during Democratic primary, and it was about the only substantive issue that was different between the President and Sec. Clinton. However, in choosing to support the individual mandate he choose to embrace a practical strategy to pool risk that appeared to have bipartisan support and could therefore be passed. In doing so, the President demonstrated the commitment of progressives and their most closely allied political party to move toward universal coverage, even if it couldn’t be totally achieved in the ACA.

Conservatives, and their most closely allied party, the Republicans, showed that they have no overriding vision for health reform by their widespread flip flop on what had long been the conservative, responsible way to achieve reform. They have many ideas, but they are mostly used to argue against the advances of the other side. In short, they are great on defense, but seem to have no offense. Offense implies having an overall grand vision for health care, and a practical strategy to move toward this vision that includes the willingness to use political capital to achieve large or small victories moving toward an overall goal. The overarching vision for progressives is universal coverage. For conservatives, I have no idea what it is. Do you?

This isn’t just a health care issue. The overarching political question of our day is how to develop a sustainable federal budget over the long term, while determining what policies are most conducive to short term economic growth.

There are two requirements to ever having anything near a balanced budget in the long run: an increase in taxes over historical levels, and some way of slowing health care cost inflation while also dealing with coverage and quality issues. The Democratic party and progressives are not perfect, but they have generally embraced the first and passed a beginning step toward the second in the ACA (first step, not the last). Republicans remain committed to further tax cuts, and still are not sure what they are for in health reform. This means they have no practical hope of achieving the policy outcome they claim to most want–a balanced budget. Cutting discretionary spending, no matter how painful, can’t get you there.

The Republican party may be on the cusp of a partial or complete short term political victory on health reform. In the long term, they are more likely to be the dog that catches the car. They need a deal on health reform terribly, and seem to be the last to know.

Author: Don Taylor

Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.

23 thoughts on “What flip flops on the individual mandate mean for Dems and Repubs”

  1. I believe your general model is correct, but there is a detail that is WAY wrong: “…an increase in taxes over historical levels, and…”

    “Historical levels.” That’s right if your study of history includes only the years beginning with “20…” I seem to remember that fellow named Clinton had a balanced budget with tax rates only slightly higher than they are right now, just before the “20…” years began. Not exactly ancient history. But more importantly, I remember (in my own lifetime, not in some yellowed tome of ancient history) when the top tax bracket was OVER 90 PERCENT. At that time the 50% bracket hit at $32,000 for married-filing-jointly, and at $16,000 for single.

    Those rates were in force for the entire Eisenhower administration and Kennedy administration, so it’s hard to believe the B.S. being put out now about the disaster of returning to the Clinton rates.

    1. Top taxes collected as percent of GDP last 50 years was 20.6% in 2000. I think it will take 21%+ given any feasible level of spending. So, we need to predictably bring in a bit more than we did with booming economy and tax code we had ’93-’01.

      1. I’d think the proposition that 20% of GDP isn’t “feasible” needs some defending. Less than that looks perfectly feasible to an awful lot of people.

        1. Maybe, but most of those people don’t want to actually cut spending to less than that. They may say so in the abstract, but you can’t get them to agree to the actual cuts. If they can’t do that, then they don’t really believe that taxes lower than that are feasible. They just like to pretend that they do.

          1. Maybe they do, maybe they don’t, but your case is hardly so strong that you can simply assume you’re right, and move on from there.

            I say, what was once feasible must be considered to still be feasible, barring evidence to the contrary. We had smaller government before, and life was not hell on Earth. We could have smaller government again. Just because you don’t want that, doesn’t make it “infeasible”.

  2. Why do the Republicans need a deal on health care? They need to win in 2012, disenfranchise some errant voters, and stay in power forever in this wonderful center-right country of ours. What does this have to do with health care?

    1. And more particularly, they opposed any variant of ACA because hanging a political failure on a Democratic president is a top priority for today’s Republicans, rivaled only by tax cuts for the rich; certainly vastly more important than anything that the rest of us would recognize as “health care policy”. Looking for something more complex or subtle is a fool’s errand.

    2. They need one to have any hope of a sustainable budget over long term, esp if unwilling to cut Defense. If aiming for balance at 18-19% of GDP it will take profound slowing of health care cost inflation. Eventually those facts will catch up.

      1. The Ryan Plan takes care of health care inflation quite nicely, thank you. And by that point odd are that Big Pharma will have found some other country willing to be its high-profit market. Win win.

        1. The Ryan plan doesn’t “take care of inflation”; it declares that inflation doesn’t exist, and that any costs belying this fiat must be born by the consumer of health care. By that reasoning, I could make a perpetual motion machine by declaring that friction doesn’t exist.

          1. You and Don Taylor seem to be making roughly the same set of assumptions about the Republicans. Why do you (and particularly Don Taylor) seem incapable of taking the Republicans at their word? Why do you think they “need” to fix the health care system in a way that moderates find acceptable? Why does Don Taylor think the Republicans “need” a sustainable budget? The Republicans don’t need or even care about either of those things. For example, Paul is absolutely right in saying that the Ryan plan takes care of inflation because, in fact, it does take care of inflation—just not in the way you or I might prefer. The Ryan plans gives everybody a fixed amount to spend on health insurance. As the cost of health care goes up people who can’t buy more health care will simply have to live or die with ever less health care. That’s not a “bug” in the Republican plan, it’s something that conservatives think is a feature. If you get sick and don’t have any money, you just simply die and reduce the surplus population. The Republicans don’t believe government should provide people with health care. Period.

            The Republican don’t need or want a sustainable budget, either. You may have noticed that when the Republicans hold power they typically run massive deficits and cut taxes for the rich as much as possible. They do this until the economy crashes and the country turns to the Democrats. When the Democrats come in, we cut spending, raise taxes and restore the nation’s fisc so that Republicans can promise more tax cuts for everybody (although they deliver only for the rich) and return to power to loot the nation’s treasury. They have done this at least twice in my adult lifetime and there’s no reason to suppose they will ever stop until the Democrats, stop buying into the Republican narrative and begin to deliver something for the people who keep voting for them. It’s as simple as that.

        2. The Ryan plan has yet to see the Commerce committee or Ways and Means, where the heavy lifting and detailed health policy will have to be done. Until they start that it is still just a general idea that has yet to have the bright lights put upon it.

          1. Don,
            Hasn’t the GOP passed a resolution in the House for the “Ryan Plan”. Perhaps this is not the same thing as actual, you know, legislation: http://www.kaiserhealthnews.org/Stories/2012/March/20/ryan-budget-medicare-medicaid-republicans.aspx

            As to the future….a policy mix that promotes economic growth will lead to, cet.par., ‘sustainable budgets’. The reverse is not necessarily true. Plus, I would aver it is a dead end political ploy because the framing is all wrong. Most people have, and will continue to hold the belief that sustainable budget = spending cuts and the easiest spending cuts will be Social Security and Medicare because that’s where the money is. I’m sure you have a heart of gold, but I cannot express my total disagreement with your emphasis enough. Thanks.

          2. “As to the future….a policy mix that promotes economic growth will lead to, cet.par., ‘sustainable budgets’”

            Not necessarily; Budgets are quite capable of growing faster than any rate of growth the economy might feasibly sustain. But I suppose in a general sense, in as much as unsustainable budgets pretty much guarantee little to no economic growth.

          3. @bobbyp
            yes, In both the 2011 and 2012 House budget resolutions they passed broad notions of Ryan Health reform. However, you cannot enact that sort of change with a budget resolution. The House commerce and Ways and Means committees will have to do the heavy lifting on those sorts of changes. One way to know that the Ryan health reform ideas (in 2011 move to totally voucher Medicare; by 2012 to do so along with option of traditional Medicare a la Wyden-Ryan compromise proposal of Nov-Dec 2011) are just broad ideas and not official House Republican “offense” is that you haven’t really heard the names Camp (chair Ways and Means) and Upton (Commerce) being invoked. What they think/want is actually more important, because first these ideas will have to get through committees, then unified version brought to House floor and get 218 votes and then on to the Senate, etc.

  3. Mitch Guthman (6/18, 2:46pm) nails it.

    Don Taylor’s column here is thoughtful, clever … and completely misses the point, in a way that is emblematic of most current writing about the GOP by liberals and moderates.

    Don’s column would be an accurate diagnosis if the GOP were basically a more-conservative version of the Democratic party. That is, a party that basically wanted to balance the budget, fix the health care system, cut spending a bit, and generally act like a responsible but more-conservative participant in governance.

    That is not even remotely a description of the modern GOP.

    They don’t want to balance the budget — they want to cut taxes on the rich, cut spending on the poor, transfer wealth upward, and run up large deficits to force Democrats to accede in their plans to gut the welfare state.

    The exact same thing is true of health care. Don Taylor writes “They need a deal on health reform terribly” but he has that exactly backwards — the GOP needs to prevent a deal on health care reform. They don’t want a solution that would extend care to all while bending the cost curve and stabilizing long-term health care costs. They want the long-term outlook for health care costs to be so dismal that the Democrats — the responsible, honest, well-intentioned fools that they are — have no option but to dismantle Medicare, Medicaid, and Social Security.

    Don, do you want to know the Republican vision for health care reform? It’s a country where rich white people can buy the best and most high-tech care in the world … and they don’t have to spend a single cent on health care for the underclass.

    How do they get there? Turn all government programs into a mix of “tax credits”, “vouchers”, and/or “block grants”. Tax credits will let the rich buy health care at public expense, while doing nothing for the poor. Vouchers will let employers off the hook, throwing everyone into the individual market (a gift to insurance companies) and their value can be capped below the rate of health care cost increase, by which mechanism government support for health care gradually withers on the vine. Block grants to states will be similarly capped, forcing states to cut back on spending, and giving GOP-run states in the South the option of redirecting their block-grant dollars towards other priorities (agricultural subsidies, tax cuts, anything that benefits rich white people instead of poor black people).

    The modern GOP is basically an alliance between people (including corporate “people”) who just want to loot the United States, people who are on a crusade to return the country to some idealized 19th-century “small government” vision, and people who just want to use American military power to bomb, shoot, torture, and humiliate.

    None of those constituencies have any incentive to reform government involvement in health care (they want to eliminate it, not reform it), nor to balance the budget (tax cuts and military spending will run up the debt, which can then be used to justify gutting the welfare state and anything else [EPA, education, etc.] that conservatives don’t like.)

    Sorry for the lengthy comment. But Don Taylor’s error here is all too common among moderates and liberals. People need to get over this habit of assuming the modern GOP is basically just a more-conservative version of the Democrats … when in reality they’re an alliance of looters and ideologues bent on destroying all vestiges of the welfare state and enriching themselves to the maximum extent in the process.

    1. @J
      I want to take the criticisms seriously and think them through. I think the bottom line is that the “political battle” is being fought on the “cutting/austerity” end of the battlefield now. The metaphor of a household cutting back carries the day even though it is false in an of itself (if my wife and I cut back on spending, we still have a mortgage and have nothing resemblign a balanced budget) and the govt is not a household. But, whatever our best metaphor is to counter this, it is 100 times less clear and more complicated. Thus, I think we have no choice but to learn to fight it out in this political space, and essentially to call the bluff of Republicans, commit to their long range goal of balance, and demonstrate that to get there it will tax tax increases and health reform. Basically, I think this is the best policy, and we have got to figure out ways to make the case for the best policy and I think many (some?) people understand large changes (incl tax increases) are inevitable and would rather hear straight talk on it.

    2. “Don Taylor’s column here is thoughtful, clever … and completely misses the point, in a way that is emblematic of most current writing about the GOP by liberals and moderates.”

      I disagree. When so somebody writes ‘policy analysis’ which simply ignores reality, that’s neither clever nor thoughtful.

      It has the surface appearance, like a fresh coat of paint on a rotten wooden door.

  4. You are probably right in saying that “the overarching political question of our day is how to develop a sustainable federal budget over the long term, while determining what policies are most conducive to short term economic growth.” (My italics.)
    But that’s only because of consensus myopia. The overarching political problem, for the USA and the world, is how to stop wrecking the climate and the prospects of future generations, while preserving the living standards of rich countries and raising those of poor ones in the process.

  5. The overarching political problem, for the USA and the world, is how to stop wrecking the climate.

    An overarching political problem is one that extends past the mid-terms all the way to the next Presidential election.

    A regular political problem is one that extends to November.

    Myopia, heretofore not known to be fatal, will kill us all in the end.

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