EVERYBODY LOVES MANDATES ... THIS WEEK. It's true, as Ezra says, that there is now a consensus among health care experts that some kind of mandate, ideally an individual mandate to participate in the health insurance pool, is a key to making any kind of health reform work. He's also right that this consensus is a somewhat recent development. Ezra attributes Obama's decision to avoid a mandate for now to fear of "the political consequences of mandates (albeit in a general election rather than primary)." What's wrong is that final parenthesis. Traditionally, as Ezra well knows, the objection to mandates has come from the left, and it has come in primaries. Al Gore objected to Bill Bradley's children-only mandate in 2000, from the left. My colleagues at the New America Foundation, which has been pushing an individual mandate since 2002, have been criticized mostly from people on the left who complained -- correctly -- that the "auto insurance" analogy is entirely inappropriate to health insurance, because unless all the other pieces are in place (community rating, guaranteed issue, and adequate subsidies) the individual mandate alone is a trap. (New America's plan has become much more robust in recent years, putting the individual mandate in the context of a complete system.) As recently as January, Schwarzenegger's proposed mandate was being attacked from the left as "criminalizing the uninsured."
What Gore warned about in 2000 -- that Bradley "would have a mandate for parents to buy insurance in the private market with a subsidy. Will hard-pressed parents purchase benefits anywhere nearly as generous as those Medicaid provides? Will they feel like they can? Or will they be forced by circumstances to use the subsidy to get more limited care?" -- was also a legitimate practical concern. If you put a mandate in first, but don't have the subsidies and structure right, people will be trapped.I'd prefer to have the mandate built in up front, but Obama's wariness of it could be more than just general-election cautiousness. It could, and I'm speculating here, reflect a healthy understanding that we are wandering into the unknown -- anyone who tells you they know exactly how something like the Edwards or Wyden plans would operate in practice is lying -- and there will be all sorts of unintended consequences. If the combination of a generous public plan and a national health insurance exchange to create private sector options doesn't do enough to expand coverage to almost everyone, then there are two variables to play with: One could increase the subsidies or impose a mandate, or both. I would assume that in the end a mandate will be necessary, but I think there's a case to be made for avoiding the technocratic hyper-certainty that has been the Achilles Heel of liberalism.
--Mark Schmitt.
