The conservatives and libertarians who earlier supported a mandate, ideally, should have been looking for the following qualities in a health care policy:
1. A very small number (one?) of categories for health care coverage and also reimbursement rates. Mandates for everyone, in other words. No Medicare, no Medicaid, no separate set of people in an employer-based, tax-subsidized health insurance sector, rather a unified system. Switzerland comes relatively close to this, and of course some commentators hope ACA will evolve into this (“means-tested vouchers”), though I suspect the scope of the mandate and the cost of the subsidies will prevent this.
2. A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor. Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence. We need to accept the principle that sometimes poor people will die just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree. We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes.
3. A modest bundle of guaranteed coverage and services. I am very influenced by David Braybrooke’s book on meeting basic needs. Yet for me basic needs truly are basic and do not involve cable TV or small probability chances of delaying death from prostate cancer.
4. Price transparency (mandated if need be) and real competition in the health care sector, including freer immigration for doctors, nurses, and other caregivers, and relaxation of medical licensing and encouragement of retail medical clinics, a’la WalMart style. This helps keep the cost of the mandate to reasonable levels. Most cost-saving innovation should come through markets. The man strapped to a gurney, bleeding, while negotiating a price with his doctor is the exception in this sector, not the rule. In any case the insurance companies can prearrange the price for that one.
5. If you wish to move away from the strictly conservative direction, you could consider price controls on some areas of medicine. Singapore does them.
6. Always convert dollars of benefits, usually a private good, into dollars of support for medical research and development, a public good. You will never end up at a margin where this is a bad trade.
7. Society should firmly believe that it is the duty of the government, first and foremost, to protect us against foreign enemies, environmental catastrophes, pandemics, and other existential threats. History shows that such existential threats are real. Alleviating individual sufferings through governmental charity can be a useful source of mutual advantage but it should be subordinate to these broader goals. Furthermore we should be determined to resist the creation of a large class of perpetual beneficiaries who will strangle the government fiscally and pull it away from these more basic duties.
I would think that such a mandate would be a serious policy option, though maybe not a first best choice. (There are also mixes of single payer backstops and HSAs, as in Singapore, and a variety of provincial systems.) Yet that is far from the ACA. We should not “blame” Obama for that difference (it’s not clear what his more utopian preferences might be, though it is clear he could not have passed them), but still it seems to me that observers can support some version of an individual mandate and oppose ACA.
I agree, by the way, with Ezra Klein’s analysis of the “motivated reasoning” of many particular individuals when confronted with ACA a few years ago. You can think of this post as an “ideal type” analysis which may or may not apply to many actual people.