A Healthy Mandate Discussion.

In today's New York Times, Ross Douthat advises Republicans to "transform Obamacare from within. With the right changes ... it could become the kind of reform that conservatives claim to have been looking for all along." I'm guessing the chances of congressional Republicans moving from their current "Burn it down!" position to one of working constructively to devise effective policy solutions are virtually nil -- after all, doing so would mean accepting that the basic structure of reform is in place and isn't going anywhere. But this does suggest one area where Democrats might invite their counterparts to come up with a solution everyone can embrace: the individual mandate.

Let's not forget that unlike many provisions of the Affordable Care Act, the mandate is a means, not an end. The end is getting everyone (or nearly everyone) into the system so you can insist that insurance companies insure everyone regardless of pre-existing conditions, and at premiums that don't discriminate. There are alternative ways to achieve the same end, by altering the punishments for failing to carry insurance. The individual mandate uses fines, but you could also use something like Paul Starr's idea of making people give up their right to both insurance subsidies and the protections of the insurance exchanges for a period of five years. So if you want to opt out, you can, but it would be a foolish thing to do. We can't be completely sure which approach would get us the closest to universal coverage, but there are reasons to think Starr's plan would work better than the fines alone.

For the last year, Republicans have been arguing that the individual mandate is a threat to liberty so horrifying that it would make Stalin jealous of its diabolical power. Democrats shouldn't be afraid to invite them to come up with their own alternative to the mandate, then we could discuss it -- so long as they agree that any solution is in the service of universal coverage. Get them to agree to that, and the question of whether we should be moving toward universal coverage will be set aside. We should get to the point where any time a Republican criticizes the mandate, they will be asked how they would get everyone into the system. That would be a discussion on Democrats' terms.

-- Paul Waldman

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