As you probably know by now, Republicans say they want to repeal the Affordable Care Act, but when you start asking them about the ACA's provisions -- like a ban on exclusions for pre-existing conditions, or subsidies to small businesses -- they'll invariably say, "Well, we don't want to repeal that. Just the awful socialist parts. We'll put that back in once we 'repeal and replace.'" The thing they do want to repeal is the one unpopular provision, which is the individual mandate to carry insurance. Unfortunately, the whole thing doesn't work without the individual mandate, which brings everyone into the system. (This is particularly true of the ban on pre-existing conditions. Jettison the individual mandate but keep that ban, and every insurer in America would literally go out of business within a year or two.)
How do we solve this problem? Matt Yglesias offers a way out, courtesy of Mitt Romney:
Romney's old idea of letting people "demonstrate that they can pay for their own health care" as an alternative to buying insurance could be a way out. The way this worked was that to escape from the mandate, you were going to have to post a bond with the state demonstrating that would be used to pay for your health care if you got sick. If you design this in a sensible way, it has the exact same effect as an individual mandate. But of course it's not an individual mandate. It's just an effort to halt freeloaders. Meanwhile, one somewhat justified complaint insurance companies will have with the Affordable Care Act is the idea that the penalty for non-compliance with the mandate is too low. But getting the penalty made tougher is a total political non-starter, and Republicans would really like to say they repealed the individual mandate. Romney's idea could offer a way out of the trap.
From a substantive perspective, this is perfectly reasonable. Unfortunately, altering the mandate in some way to make things more palatable -- either this way, or with Paul Starr's plan, which would require you to foreswear any use of the insurance exchanges for five years if you choose to go without insurance -- means making the transition to the full implementation of the ACA smoother. In other words, a deal to do such a thing would require Republicans to accept the ACA, and agree to make it work better. The alternative course -- do everything they can to undermine it, and hope that eventually they get control of the White House and both houses of Congress so they can repeal it -- is always going to be more appealing.
But we may well see Romney advocating that Republicans do just that. He has to find some way out of his dilemma, which is that he passed a plan remarkably similar to the ACA. I hesitate to give Sarah Palin and Newt Gingrich any ideas, but if I were them, I'd start calling him "Mandate Mitt." To head them off, he could start talking about this one rather technical way in which RomneyCare differs from ObamaCare. Who knows -- he might just convince some Republicans that he did something totally different.
-- Paul Waldman
