Let’s just start over?

May 31, 2011

I get asked to speak about health reform on a fairly frequent basis. It is actually quite fun, because health reform is so topical and there is always something new going on. I also enjoy the subject because there is always a range of viewpoints in any given audience: from those who strongly advocate for a single payer system to those who think the whole thing should be scrapped. It is interesting to hear the foundations for the various points of view.

At a recent talk to a group of physicians, one individual—clearly an opponent of the Affordable Care Act—raised the idea of just repealing the law and starting over. He was reacting to polls that say many Americans think the Act should be repealed entirely or in part.

The problem with this conclusion is if you go deeper into the polls, you actually find that most Americans like the core elements of the law. The two pieces people don’t like are (1) the individual mandate, (2) and the excise tax on high cost (“Cadillac”) health plans.

The problem with repealing just these two pieces is it is hard to get the “good things” in health reform without some form of these two relatively unpopular ideas.

Two individuals who understand this point very well are on the Republican side of the aisle: Newt Gingrich and Mitt Romney. Both have come out in support of the individual mandate in recent days—though they both also criticized key elements of the Affordable Care Act.

It was most interesting to hear the terms that Gingrich and Romney used in this discussion because both are actually quite knowledgeable about health insurance related issues. Both used the term “free rider” in their defense of the individual mandate, a term for the concept that people without health insurance still have to be treated and stabilized in a hospital. The cost of care for those individuals ends up being paid by all the rest of us who have health insurance. Thus, the uninsured become “free riders” in the health care system and the only way to deal with that problem is to make sure that everyone is insured one way or the other. The individual mandate is one among several alternatives for accomplishing that goal.

The individual mandate is in fact a truly conservative idea. Oh…eons ago, in the ’90s, the idea was most strongly advocated by those with strong Republican and conservative credentials and criticized by those on the left.

Indeed, Newt Gingrich first endorsed the concept in 1993, during the Clinton health reform years when a very different structure for funding of health insurance was on the table. At the time, Newt likened requiring individuals to purchase health insurance to the requirement to purchase automobile insurance.

Similarly, when discussion about health reform began in earnest in Massachusetts in 2004, all proposals that were put on the table included the idea of an individual mandate. In 2006, then-Governor Romney signed the bill into effect while vetoing a number of its specific provisions. The individual mandate was not one of the provisions he either vetoed or criticized. And, most recently in Ann Arbor, Mich., Governor Romney again noted his support for the individual mandate in Massachusetts, though he argued that the Massachusetts approach should not necessarily extend to other states.

Despite the fact that both Newt Gingrich and Mitt Romney are criticizing the Affordable Care Act as an overreach by the federal government, the law’s core issue– the issue under attack in the courts and by the public – is one that both men fundamentally support.

And, both men also understand this truth: there are truly only a few ways to get to universal coverage (or anywhere close to it), and the other ways are even more repugnant to a conservative world view than the individual mandate.

So as long as there is agreement that the goal of universal coverage is a good thing—if for no other reason than to deal with the free rider issue—the individual mandate has to end up in the discussion, and “starting over” to produce something else is unlikely to satisfy the critics.

Part of what makes health care so interesting is how opinions shift over time. Who knew, 20 years ago, that Democrats would be relatively united in support of the individual mandate while Republicans would be divided?

Hmmm – this is going to be a most interesting political season.