Did Democrats Bungle The Sale Of The Individual Mandate?
Democratic rhetoric since the Supreme Court decision on ObamaCare raises the question of whether they made a political mistake.
In the days since the Supreme Court upheld the Constitutionality of the Affordable Care Act I have noticed a decided shift in the rhetoric coming from the White House, Congressional Democrats, and Democratic Party officials and surrogates in their defenses of the individual mandate. Obviously, this is partly to be expected given the fact that their signature piece of legislation has just been upheld as Constitutional by the Supreme Court of the United States after a 27 month period in which it was under constant legal assault from conservative activists, attorney, law professors, and legal analysts. So, I suppose they are entitled to their victory lap. We all know that the opponents of the PPACA, of which I remain one, would be doing the same thing if the Court had struck down the law last Thursday.
However, what I have noticed over the past four days isn’t just a victory lap, but a decided change in tone, and a turn to an idea that we’ve never seen from the defenders of the PPACA before.
The words I have been hearing from Democrats over the past four days all center on things like “personal responsibility” and “free riders” and the idea that people who can afford to buy health insurance but refuse to do so should not expect the health care system and, ultimately taxpayers, to pay for the expenses they might incur in case of a catastrophic injury or health crisis. Indeed, this is the very argument that Mitt Romney used to justify the individual mandate in the Massachusetts health care reform plan, as Joe Klein described it in what I can only call an overly obsequious column way back in 2005:
Governor Mitt Romney is a Massachusetts politician with a long, narrow face, an impossible shock of hair and presidential ambitions. He’s also pretty tall. But any resemblance to another recent Massachusetts politician who ran for President evaporates the moment Romney opens his mouth: his demeanor and metabolism are the opposite of John Kerry’s—informal, conversational, enthusiastic and speedy. Or maybe it was just that we were talking about his rather remarkable plan to bring mandatory universal health-care coverage to Massachusetts by next summer, the first time a Republican has tried to pull off this most Democratic of policy goals.
“I don’t like calling it universal coverage,” he told me last week. “That smacks of Hillarycare. But I do think we’ve come up with a way to get everybody covered through the free-market system.” Romney’s way is not new: policy wonks call it an “individual mandate” system, but the Governor doesn’t like that term either. “I call it a personal responsibility system,” he said.
Or, as Romney put it a few months earlier:
“We can’t have as a nation 40 million people — or, in my state, half a million — saying, ‘I don’t have insurance, and if I get sick, I want someone else to pay,’ ” says Romney, a Republican who says he might run for president in 2008.
It’s the question behind all health care debates: Who should pay?
Romney’s plan says everyone should: The state would work harder to enroll all residents eligible for Medicaid; employers, most of whom already offer insurance, would be encouraged to continue doing so voluntarily; and individuals who don’t have insurance would have to sign on to one of two new insurance pools, one of which would be subsidized for lower-income residents.
As a libertarian, there is much about the free rider problem that is persuasive. Indeed, libertarian economists and political theorists have written volumes of work based entirely on the problems the free rider problem presents for political and economic theory. The most famous example of that is the idea of the Tragedy of the Commons. In the context of health care, if people know that they can receive free, or nearly free, care via emergency care then there’s arguably an incentive for those who can afford the insurance that would cover catastrophic care to decline to get such coverage. In the end, that means that health care costs go up for everyone else.
Now, obviously, there’s a certain class of people for whom the lack of insurance isn’t a matter of choice. They are the one’s who don’t have a job that provides health benefits, can’t afford it because they are too poor, or can’t qualify for it because of pre-existing medical conditions. It’s unfair, obviously, to label such people as free riders because they couldn’t get affordable insurance even if they wanted to. However, the PPACA has regulations that covers such people, and the PPACA includes subsidies that would cover those people who cannot afford to pay for health insurance. And, the supporters of the PPACA tell us that the regulations that include those provisions would bankrupt the insurance industry unless we have an individual mandate.
So, that brings us to the question I have.
Where was the “personal responsibility” and “free rider” language before 10:30am last Thursday morning? Leaving aside the fact that I don’t support the individual mandate, I have to wonder why nobody thought of coming up with these arguments before, especially given the fact that the “personal responsibility” angle is the precisely the argument that Governor Mitt Romney used to sell the RomneyCare mandate when he was Governor. I’m not sure whether it would have changed the course of public opinion, but it strikes me that selling the mandate as a “tax on free riders” would have gone a lot better for the Obama Administration than the arguments they used, such as they were. Hell, it couldn’t have gone any worse, could it?
Thanks Doug, I’m 66 years old and have a masters and that was a new word for me. For those who like me this was a new word here is the Websters:
The Democratic justification for their own plan was pretty weak, but they seem to have been handed a victory anyway.
Not only did the Supreme Court rule in their favor, that new Kaiser poll says that most Americans want to move on and just do it.
I think we will now. What else can happen when those old clips of Romney make the strongest case for mandate as individual responsibility and a sensible idea? Seriously, that clip is better than I’ve seen Obama do. Romney says “I like mandates.”
Even when Zombieland is your target audience it’s pretty tough to sell them a pile of crap and to expect them to mistake it for Shinola.
Where was the “personal responsibility” and “free rider” language before 10:30am last Thursday morning?
Being slowly marched over by a horde of Tea Party activists who wanted to keep government out of Medicare.
BTW I am a big fan of one of the English Languages’ greatest wordsmiths, Aldous Huxley and I don’t recall obsequious. I think my favorite Huxley line is from Antic Hay:
Modulo,
Nonsense, I don’t recall any argument of this type coming from advocates of the bill.
@Doug Mataconis:
I’m sure you can find mandate bound to personal responsibility in OTB archives – amongst comments.
@Doug Mataconis:
Jesus, Doug:
https://www.outsidethebeltway.com/from-the-irony-department-individual-mandate-edition/
@Tsar Nicholas:
THAT is the kind of complete mental breakdown that flags a victory.
It’s a shark jump.
@Doug Mataconis:
But to be fair, maybe the overall strategy of getting the ACA through Congress was centered around not making an insane situation more insane. And having an African-American President saying to angry whites worried about death panels that the mandate was being done in order for the reason of ‘personal responsibility’ may have added to the nuttiness.
@Modulo Myself: and @john personna:
Quite obviously I am referring to the political strategy used by Democrats to sell the mandate, not what may have been said in random blog comments and blog posts
@Doug Mataconis:
OK, speaking only of Obama, he won with a weird strategy, a slow game.
People were certainly making the free rider argument before the SCOTUS decision. For example,
http://voices.washingtonpost.com/ezra-klein/2011/02/the_policy_questions_behind_th.html
Anytime an ACA supporter brought up EMTALA in a discussion about the mandate (and I’m pretty sure that was brought up several times on the OTB forums), they had the free rider problem in mind.
As to why Obama and the Democrats weren’t pushing the idea earlier, I suspect they made a judgement call that saying that people who don’t buy health insurance are freeloaders is not good politics. Now, events have forced them to confront the issue head on.
@john personna:
Whether Obama “won” or not is still an open question
It’s actually a good and fair question.
The central tenet of “small government” types is, or used to be, personal responsibility. It’s driven me nuts over the last decade to see the complete dismissal of it (personal responsibility) by the leaders of the conservative movement.
I wonder though, if that argument needed to distill for a while for a Democrat of make with out being laughed off by the right wing… now at least, it could be made.
I think it’s a great idea to coop.
Oh absolutely! There’s always the hope that Mittens and 51 senators will wipe out this travesty…of course, it’ll be a little hard for Romney to win the White House in the first place if he has to argue against something based on what he did when he was governor of Massachusetts…
@Doug Mataconis:
It would be no fun calling things if we waited for December.
I’m calling it now, with some risk, but not as much as you’d like 🙂
No, it couldn’t. This was the worst sales job in political history.
Mr. Obama is good at the soaring rhetoric, and good at one-time explanations, and good at put-downs, but he is not good at the day-in, day-out sales work that goes into persuading people. He’s not good at relating a policy to the lives of regular people. If Bill Clinton had taken on this sales job the ACA would be polling at 70%.
@ Doug
It’s closing pretty quicky…
The latest Gallup tracking poll finds President Obama has opened up a five point lead over Mitt Romney, 48% to 43%.
Meanwhile, a new Kaiser poll finds a majority of Americans — 56% — now say they would like to see the law’s detractors stop their efforts to block its implementation and move on to other national problems.
@Doug Mataconis:
I agree with the general point that democratic surrogates have been few and far between in making the case for the mandate. It’s bad enough that off the top of my head I can’t think of any. What I’ve definitely seen though is the President make the case over and over, in interviews, on the stump, in response to town hall questions, etc.
One example from around a year ago:
http://abcnews.go.com/blogs/politics/2011/11/obama-confident-about-health-care-law-having-its-day-in-supreme-court/
The real election in 2008 was the democratic primary and Obama ran against the mandate. Focusing on selling the mandate opens up Obama to lots of attacks (attacks that could use Obama’s own words against him). If the mandate was found unconstitutional then in hindsight that would have looked like a petty concern. If anyone other than Romney was nominated to run against Obama then not selling the mandate would have also looked bad. But the fact is that the mandate was found constitutional, and the guy running against Obama can’t credibly attack him on it.
And of course there’s that 2009 George Stephanopoulos interview which has been getting so much airplay since the media decided that it makes any kind of sense that what Justice Roberts writes in a legal decision somehow invalidates non-conservative jurist political rhetoric, or even more ridiculously makes previous rhetoric all of a sudden a “lie.”
http://www.youtube.com/watch?v=_0ZUBMqMnWs
No “free rider” rhetoric is due to a couple of things. One, many of the people who don’t have insurance because their employer doesn’t offer a plan do not make enough to buy any more than the scam policies, such as the one McDonalds offers their employees. They do not consider themselves thieves. There was a period in my state where the insurers would not issue individual policies at all, due to a pissing match over existing conditions. “Free rider” is an insult to those people, and indicates a lack of understanding to boot.
Two, “Libertarians” are not always as intellectually honest as you. In fact, I believe a great many of them are sort of unaware that they are rationalizing not wanting to pay a fee by means of a contrived legal arguments dealing with abstract notions of what they wish the Founders were thinking. The Libertarians may like to think of themselves as brave pioneers, but you won’t find a large percentage of them sewing up their own wounds with a strand of horse hair, or gutting out appendicitis to it’s sad and extremely painful conclusion went a phone is in reach.
So, as a sales strategy it may be losing more than it is helping. They needed to grab the middle. Partisan Republicans? It wasn’t going to work on them anyway.
Doug proves his partisan hack bonfides.
Yes …. The mandate was always about getting one step closer to selling Broccoli…it was never about getting the common cold out of emergency rooms – a problem that costs the rest of us nearly $1000 a year. It was always about Broccoli. You caught them. Brilliant analysis.
Let me get this straight: it is the epitome of “individual responsibility” to participate in a collective plan that, in essence, redistributes the costs and benefits of our health cares system on a “from each according to their ability, to each according to their needs” basis?
Someone done rewrote the definition of “individual responsibility” when I wasn’t looking…
Jenos,
Question:
If you can afford health insurance and refuse to pay for it, why should taxpayers pick up the tab when you suffer a catastrophic injury requiring extensive medical care?
@Doug Mataconis: As long as “the taxpayers” are free to attempt to recoup that tab from me, I don’t see the problem. And as insurance plans usually negotiate lower rates from providers, then that tab should be for the full standard price.
Which, come to think of it, is how things work now. Care is NOT denied, but people are responsible for the bills later.
I’m not saying the current system is perfect, but it’s a hell of a lot better than the abortion that is ObamaCare. Like Nancy Pelosi said, we had to pass the bill before we could see what’s in it. And I just figured out one more of the scams in it.
The plan is dependent on everyone paying in, often for more coverage than they need. This is especially true on the young, who rarely need full-boat coverage. So it’s the young, healthy who contribute for us older, sickly types to take out more than we pay in.
However, with a good chunk of the young to be carried by their parents until age 26, their overpriced premiums get passed back on our generation — who don’t see it as getting screwed by the government, but being good parents and taking care of their kids.
Nicely played.
Jenos,
Do you what the actual rate of reimbursement on hospital bills for people w/o insurance is? It’s pretty darn low. Do you think hospitals should be able to turn someone away if they don’t have insurance? If not, how you propose paying them for the money they lose?
I’m not saying I support the mandate but the free rider issue is a real one
@Doug Mataconis: Question back:
Do you disagree with my characterization of the PPACA? Do you find it inaccurate? Yes, I did choose my terms most carefully, and used charged quotations to describe it, but is it inaccurate?
@Doug Mataconis: So, there’s no way to improve the current system? The only solution is to totally trash it and try something wholly different?
I don’t think so. As the saying goes, “mend it, don’t end it.”
Jenos,
There are plenty of ways to improve it. The GOP, however, refuses to put a plan on the table. Instead, they just whine. Which is why I’m glad I’m not a Republican
@Doug Mataconis: So, because the Repubs didn’t put up a plan you could support, you decided against putting pressure on them to do so and instead you’re backing a scheme that will, in all likelihood, make things far worse? Sounds like “change for the sake of change” to me.
Jenos,
What part of “I don’t support the individual mandate” don’t you understand? This post was purely a post about political strategy.
As for the GOP, you can’t fight something with nothing and, right now, they have nothing.
(And by the way, it’s not that the GOP didn’t put up a plan I could support, they haven’t put up a plan at all. That’s irresponsible governing)
@Doug Mataconis: OK, maybe “backing” is a bit strong. How would you characterize your posts on the subject? You’ve hardly been its most strident critic. Hell, you’ve been a hell of a lot harsher on its critics than you have its backers…
@Doug Mataconis:
Really? His legislation passed Congress, he signed it, the Supreme Court upheld it.
He won. The only thing that can turn the win into a loss is a big string of “ifs” that just got iffier after the SC ruling last week.
You’re on record not supporting the mandate. What reforms do you support then?
@Herb: Huh. You show up, and suddenly every single comment I made has a down-vote.
Dude, look up the word “subtle.”
@Jenos Idanian #13: Wasn’t me, dude. Not only do I use the ratings sparingly, if at all, I almost never give a thumbs down.
And trust me, dude, if you were going to get some down thumbs, I wouldn’t have started today.
@Doug Mataconis: But but but Both sides do it?
On a serious note it seems Jenos isn’t quite aware of the large amount of people who get away without ever paying for their emergency room bill. What’s even worse is the number of people who show up at the ER for things that should of been taken care of much earlier at a much cheaper price.
Talk to about any nurse that has been in the ER for a length of time and they will fill your ear with stories..
@Jenos Idanian #13: Ever heard of lurkers? They get to “up or down” vote, too.
“Which, come to think of it, is how things work now. Care is NOT denied, but people are responsible for the bills later.”
No, they get written off. Our collection rate for my practice is well under 10% for those patients. For the trauma patients and premie OB patients, our hospital writes off bills well over $100,000.
As to Democrats and bungle, I think if you look in the dictionary they are synonyms.
Steve
@Jenos Idanian #13:
I think those were the funniest lines. Jenos hasn’t quite registered what “the current system” really is.
The ER is not free. If you can pay, you will.
If you do not pay, your debt will be sold to a collection agency. If you still do not pay, you will be sued. Unless you go bankrupt, a lien can be placed against your house, and your wages can be garnished. Any future assets you acquire can be taken to pay off the debt.
For a private hospital, you may be able to negotiate a lower price, but that will probably be income dependent. At a public hospital, you will usually be means tested before you leave, and if you do not qualify, you will be billed. See above for that process. If you qualify, you will never receive a bill.
Many large cities have one or more public hospital(s) that serve the poorer communities, and many of these are also teaching hospitals for medical schools (doctors and nurses). Many also have a clinic system to address the ongoing medical issues of their users. This also allows the future doctors to practice what they have learned. People who can afford but choose not to buy insurance usually do not use these hospitals.
If somebody knows where one of these “free” ER’s exist, please publish the location. For those who know I am wrong, try it. Go to the ER with a cold, and tell them that you do not have insurance. Please be sure to report on your findings.
The Democrats bungled when they came up with another government mandate that is not constitutional.
@steve:
Sure, and as many have noted, that’s the kind of thing that is added to the insurance bills of the covered. The stubborn-most right opposes taxes on the tax bill, and refuses to acknowledge “taxes” on the insurance bill. We know this, it’s old news.
That’s what makes “you can go to the emergency room” just a partial argument and deflection. It’s only offered briefly, before retreat to some other equally partial argument.
@matt:
Jenos (in his previous incarnation as Jay Tea) knows a great deal about shifting the burden of ER costs onto the general public – he went without health insurance, fell dangerously ill, received life-saving care, and then had to negotiate with the hospital to pay pennies on the dollar because he couldn’t afford the going rate for his treatment.
This is the system he believes works best, because hospitals can just “write off” the unpaid bills to some magical, alternate reality where there are no financial consequences to anyone.
@Clanton:
Sorry, Clanton, but A) the Dems didn’t come up with many of the ideas that became Obamacare and B) it’s constitutionality was upheld last week.
Doug is right on with these statements:
I doubt Obamacare was everyone’s first choice as what the health care reform should look like, but plenty of people decided to support it when it became clear it was the only option being considered. The GOP aren’t obligated to create a health care plan, but it shouldn’t be a surprise to it’s supporters that something is better than nothing.
@Ron Beasley: And please note Mr Beasley that Our Host outdid himself in another respect: He spelled it correctly! In fact, a quick reading of the posting doesn’t reveal a single typo. Could our friends here at OTB have sprung for a proofreader? Inquiring minds want to know.
About Emergency Room care: I was working a few years ago in a major university hospital in a large eastern metropolitan area (well, hell– the University of Md Trauma Center in Baltimore). Quite possibly the most advanced “ER” in the world. There were dozens of MDs there from all over the world on Fellowships, Residencies and such. Got to talking to a group of them about what differences they noticed between patient populations in our country and the ones they saw in their home countries. They were unanimous: Diabetes. In Taiwan and England and Israel, diabetics have such thorough and complete medical care through their normal access to “Primary Medical Providers” that they are almost never seen in ERs, according to this group.
About collecting bills for Emergency Room care: Apparently Mr Jenos thinks this is cost-free. He is ignorant of many things besides this — but this does stand out. It is very damn expensive to collect money from ill and/or injured people. And much can never be collected.
Uncollected bills are sold to people with much less compunction than hospital account clerks and results in people ‘paying down’ their wealth until they are below poverty/medicare thresholds, in people losing their careers, houses, vehicles and such. Which does very little good to the economic health of the city one happens to reside in.
And finally in answer to Our Host’s original question — why did the Administration not stress the ‘free rider’ aspect of the so-called-mandate? — it is obviously because those likely to be ‘free riders’ are the poor and young and under- or un-employed. And most of those are likely Obama voters.
@Rufus T. Firefly:
Oh, and anyone who still doubts that Jenos IS Jay Tea should note the similarities between this paragraph from my link above:
and this paragraph from just yesterday:
@JohnMcC:
So why doesn’t the other side name them? Because they’d rather have you believe the “tax increase” affects everybody.
@Rufus T. Firefly:
Ooooo. Nice.
The stupidity of this statement is so blinding, I will just let it stand on its own.
@Rufus T. Firefly: So, Jenos Idanian #13 is/was just as much a health care mooch as the poor and indigent. For all of his blather, he’s still one of the ignorant who continually votes against his own self-interests.
@ Nikki
A lot of rank and file conservatives take their cue from Republicans in Congress. They like to use services, just don’t want to pay for them.
@Doug Mataconis:
Are you serious? What exactly do you think the justification was? “We want the mandate because we think it is fine for the government to tell everyone what is best for them.”
That’s only in the imagination of conservatives (or libertarians) who refuse to believe that liberals are capable of rational thought. The entire purpose of the mandate is to allow the legislation to require insurance companies to cover pre-existing conditions without creating an insurance company death spiral of higher premiums and fewer healthy customers. You may not recognize it but it is all about the free-rider problem.
@DRE:
This discussion made me think of a definition of my own political philosophy (which I think is common among Democrats.) I am a libertarian who takes externalities, including free-rider issues, seriously. In addition I understand that private property only exists in the context of government, and often has a problematic history.
Sorry for the detour.
One answer to this problem of Federal programs being forced onto the people would be the principle of nullification by the states of laws and programs that the states feel are unconstitutional and an abuse of Federal powers.
Read more interesting and enlightening information about this at:
http://www.tomwoods.com/books/nullification
@ Clanton
A stale crouton is more interesting…
15,000 pages of “instructions”
thousands of new bureaucrats
billions of dollars – just to start up!
Can you imagine trying to call and order a prescription or get question answered?
@Racehorse:
I know the right is selling this “centralized” idea, but that’s not the way it works. You don’t call the government, or their 15K pages, to order or fill a prescription.
If you have Kaiser, you keep calling Kaiser.
For the typical person with medical insurance, there is no change in routine.
If you don’t have insurance, you get it, and start calling your new provider (a private company) for whatever you need.
@DRE: Doug is a strange case. He’s intelligent, he writes well, and I find his viewpoint to be rational even if I don’t agree with it. But he suffers from a kind of libertarian Tourette syndrome resulting in odd outbursts like the one you quoted. It’s very unfortunate, and I’m sure it’s a source of sadness to his friends.
@Stan:
It might be worse. There is an intellectual laziness in picking the weakest of an opponent’s arguments and answering only that. It means, say that you never have to think about the power of the 1%, because the 99% are only “drum circles” and “pooping on police cars.”
Or, you never have to worry about tax rates for the rich, because any tax increase is “class warfare.”
@john personna: More importantly, I think, Doug doesn’t seem very able to apply any skepticism to his own assumptions.
@john personna: Thanks for your answers. I have tried to find a site for answers, but you are doing just fine on clarifying some of this.
How can I get a copy of the ACA?
@Racehorse:
http://dpc.senate.gov/dpcissue-sen_health_care_bill.cfm
or
http://www.gpo.gov/fdsys/search/pagedetails.action?packageId=PLAW-111publ148