Republican support for the individual mandate
As far as I have been able to find, Stuart’s 1989 brief is the first published proposal of an individual mandate in the context of private-sector-managed health systems. In 1991, Mark Pauly and others developed a proposal for George H.W. Bush that also included an individual mandate. While others credit Stanford economist Alain Enthoven with the idea, Enthoven’s earliest published reference to an individual mandate was an indirect one in the 1992 Jackson Hole paper.
In 1992 and 1993, some Republicans in Congress, seeking an alternative to Hillarycare, used these ideas as a foundation for their own health-reform proposals. One such bill, the Health Equity and Access Reform Today Act of 1993, or HEART, was introduced in the Senate by John Chafee (R., R.I.) and co-sponsored by 19 other Senate Republicans, including Christopher Bond, Bob Dole, Chuck Grassley, Orrin Hatch, Richard Lugar, Alan Simpson, and Arlen Specter. Given that there were 43 Republicans in the Senate of the 103rd Congress, these 20 comprised nearly half of the Republican Senate Caucus at that time. The HEART Act proposed health insurance vouchers for low-income individuals, along with an individual mandate.
Newt Gingrich, who was House Minority Leader in 1993, was also in favor of an individual mandate in those days. Gingrich continued to support a federal individual mandate as recently as May of last year.
It would seem that 1990s conservatives weren’t concerned with the constitutional implications of allowing Congress to force people to buy a private product. “I don’t remember that being raised at all,” Mark Pauly told Ezra Klein last year. “The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax…So I’ve been surprised by that argument.”
Stuart Butler’s USA Today op-ed
Last October, prompted by a Wall Street Journal piece by James Taranto, I recounted how the Heritage Foundation was once the leading conservative advocate of the individual mandate. In response to various articles of this stripe, Stuart has published an op-ed in USA Today, in which he describes as a “myth” the idea that Heritage invented the mandate. “I headed Heritage’s health work for 30 years,” he writes. “And make no mistake: Heritage and I actively oppose the individual mandate, including in an amicus brief filed in the 11th Circuit Court of Appeals to the Supreme Court.” He notes that his proposal struck a contrast with Hillarycare, and that Milton Friedman also called for an individual mandate:
The confusion arises from the fact that 20 years ago, I held the view that as a technical matter, some form of requirement to purchase insurance was needed in a near-universal insurance market to avoid massive instability through “adverse selection” (insurers avoiding bad risks and healthy people declining coverage). At that time, President Clinton was proposing a universal health care plan, and Heritage and I devised a viable alternative.
My view was shared at the time by many conservative experts, including American Enterprise Institute (AEI) scholars, as well as most non-conservative analysts. Even libertarian-conservative icon Milton Friedman, in a 1991 Wall Street Journal article, advocated replacing Medicare and Medicaid “with a requirement that every U.S. family unit have a major medical insurance policy.”
My idea was hardly new. Heritage did not invent the individual mandate.
Stuart says that Heritage’s version of the individual mandate contained “three critical features” that distinguish it from Obamacare’s mandate: (1) it required people to buy catastrophic coverage, rather than more expensive comprehensive coverage; (2) it was primarily financed “through the carrot of a generous health credit or voucher…rather than by a stick”; (3) Heritage’s mandate “was actually the loss of certain tax breaks…not a legal requirement.”
In fairness to Heritage’s critics, it’s worth pointing out that: (1) Heritage proposed the individual mandate in 1989, well before Bill and Hillary Clinton were on anyone’s political radar screen; (2) Obamacare and Romneycare both finance individual insurance purchases through generous vouchers (via the exchanges); (3) Obamacare’s mandate is “enforced,” weakly, by withholding tax refunds.
Why has Heritage changed its mind?
Stuart goes on to give four reasons why he and Heritage no longer support the mandate: (1) a mandate isn’t necessary because “the new field of behavioral economics taught me that default auto-enrollment in employer or nonemployer insurance plans can lead many people to buy coverage without a requirement;” (2) “advances in ‘risk-adjustment’ tools are improving the stability of voluntary insurance,” as illustrated by the Federal Employees Health Benefits Program; (3) Obamacare’s mandate forces people to buy comprehensive coverage rather than catastrophic coverage; (4) Obamacare’s mandate is unconstitutional.
Stuart, of course, is perfectly entitled to change his mind, and the reasons he gives for having done so are ones I’d agree with. (I would also point out, as I do repeatedly in this space, that the “free rider” problem is grossly exaggerated, and that an individual mandate actually increases free-riding.)