April 19--The intense debate over whether the U.S. should oblige all citizens to have health insurance has been accompanied in recent days by another spirited squabble: Just whose idea was it in the first place?
When it comes to the individual mandate in the Affordable Care Act, which the Supreme Court is expected to rule on in June, no one claims original ownership.
Democrats who once opposed any mandate, including then-Sen. Barack Obama, now embrace the idea of requiring individuals to buy insurance. But President Obama has said that idea was born on the Republican side of the aisle. He points to 1989 writings published by the conservative and influential Heritage Foundation, including a paper titled "Assuring Affordable Health Care for All Americans."
But Heritage Foundation officials, including Stuart Butler, who wrote that paper, respond that they aren't to blame for the current law. Butler recently published an op-ed piece in USA Today titled "Don't Blame Heritage for the Obamacare Mandate."
But Butler did use the word "mandate" in his 1989 writings.
"Mandate all households to obtain adequate insurance," Butler wrote. "Neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement."
In the early 1990s under President Clinton, a health care overhaul, which opponents labeled "Hillarycare," was debated rancorously. The foundation repeated its call for an individual mandate rather than foisting all coverage onto employers.
Some libertarians took issue with that position, but the foundation didn't budge.
"It is idle to talk about personal freedom outside of personal responsibility," foundation senior fellow Robert Moffit wrote in defense of a mandate.
But Butler, Moffit and the foundation subsequently recanted.
"I've altered my views on many things," Butler wrote in his op-ed piece. "The individual mandate in health care is one of them."
Butler explained that he now believes strategies such as automatic enrollment in insurance programs, requiring a written statement to opt out, and large tax credits for health insurance spending will greatly increase coverage, making mandates unnecessary.
He said that even in 1989 he was speaking about a mandate not for comprehensive insurance, as contained in the current law, but primarily for catastrophic insurance -- although in a subsequent lecture he said a mandate "might also include certain very specific services, such as preventive care, well-baby visits and other items."
Moffit, in an interview with The Palm Beach Post, also said the foundation had once proposed a mandate for catastrophic care.
"It was a policy endorsed by many conservative economists at the time, as well as the American Enterprise Institute," he said, naming another major conservative think tank.
"It was for catastrophic care and designed to stop free riders," Moffit said, referring to uninsured people who accumulate large hospital bills that fall to taxpayers.
But he said the foundation moved away from the idea of a mandate long before Obama was elected president. In the meantime, after John Edwards and Hillary Clinton, rivals for the 2008 Democratic presidential nomination, endorsed a mandate, Obama eventually climbed aboard.
Joseph Uscinski, a University of Miami political scientist, called the evolution "a very strange new juxtaposition of positions." But Republicans' rejection of conservatives' earlier position doesn't surprise him, he said.
"The idea of a mandate was never a mainstream Republican position," Uscinski said. "It was discussed in a few pockets, but most Republicans were in favor of a free-market solution, not forcing people to buy something. The evolution of the Democrats is more interesting."
Steven Ullmann, a UM health care management expert, said the fact that conservatives had floated the idea and some Republican members of Congress had voiced support for it probably were factors in Obama's adopting it.
"That's part of it -- the fact that it originally had been a Republican idea," he said. "He probably figured this would be a consensus builder, but ultimately it wasn't."
Another influence on Democrats was the Massachusetts health care law signed in 2006 by then-Gov. Mitt Romney, today Obama's chief GOP rival for the White House. A famous photograph of Romney and Sen. Edward Kennedy, D-Mass., celebrating together at the signing of the act helped create that image of middle ground.
"Kennedy worked a long time for universal health care and, yes, I'm sure the fact that he backed the Massachusetts law helped bring Democrats to the right on the issue," said Florida Atlantic University political scientist Kevin Wagner. "But it wasn't so much that middle ground was found. What has happened is that both parties moved to the right, which is why is there is still no consensus."
Democrats, many of whom had favored a more liberal public option, abandoned that idea when it became clear it would never pass in Congress. They moved to a position that included insurance purchases from private companies and a mandate.
But by that time, conservatives had abandoned their previous position. Then came the tea party movement, which has emphasized strict adherence to the Constitution. Many members consider the health care law creeping socialism and any federal mandate as unconstitutional. The Heritage Foundation also has called it unconstitutional.
Elizabeth Price Foley, a Florida International University law professor who was in the Supreme Court gallery March 27 during arguments on the mandate, is convinced the court will strike it down.
It that happens, Foley said, Democrats could come back with a plan that would expand Medicaid or Medicare, while she sees Republicans embracing a variation of the Heritage plan employing tax incentives and credits and market changes, including the ability to buy insurance across state lines. But she doesn't see either one passing Congress anytime soon because of cost.
"If we didn't have the deficits we have, if we were in better economic times, you might find some receptivity, but not now," she said.
In the end, FAU's Wagner finds the evolution of the positions intriguing. Although Obama may have expanded the idea that Butler first enunciated, Wagner sees a clear line leading from one to the other.
"Obama adopted an idea that originated with a conservative think tank and he gets labeled a socialist for it," said Wagner. "Now that's ironic."
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