The rhetoric of reform…

In the discussion over the individual mandate among the presidental candidates, blogger Ezra Klein, NY Times columnist Paul Krugman, and others with good liberal credentials are making the progressive case for an individual mandate, and even making it a litmus test for a serious health proposal.

ARE INDIVIDUAL MANDATES A MUST? The argument goes like this: progressives believe in social insurance, where everybody needs to participate. If there isn’t a requirement that we all need to contribute to health care, you undermine the fabric of social solidarity, the concept of universality. There’s something to that.

Other commentators don’t see the “individual mandate” issue as the defining issue, including Matt Ygleisa at The Atlantic, Kevin Drum at the Washington Monthly, Richard Eskow at the Sentinel Effect (including an interview with Obama’s health advisor), Timothy Noah at Slate, and even former Labor Secretary and UC Professor Robert Reich (and Ezra’s editor at The American Prospect), albeit all for different reasons. (I also posted a reply to Ezra’s first and most recent posts.)

All of these commentators seem to indicate that the Clinton (or Edwards) plans, with an individual mandate, would be far better than the status quo. In the context of a good proposal, they don’t make individual mandates something to attack; but they don’t believe the individual mandate is the essential dividing point between Clinton and Obama, or between a workable or progressive proposal and one that is not.

FRAMING THE QUESTION: Some have seen the individual mandate not as a liberal but as a conservative construct, and not just because of it origins with moderate Republicans like Senator Chafee in the early 1990s, and Governors Romney and Schwarzenegger more recently. Under this belief, the individual mandate enforces a more conservative point of view, that of personal responsibility.

As Health Access put forward in our critique of an individual mandate from 2006, an individual mandate implies that the issue is that people need to be required to take up coverage, rather than acknowledging and addressing the real barriers that exist for people to get they coverage they actually want. The Health Access paper was responding to previous legislative proposals, including those by former Assemblyman Keith Richman (R), which did not propose to do much to address those barriers.

This year, Governor Schwarzenegger took the implications of the individual mandate seriously, meaning putting in place significant subsidies, a minimum employer contribution, and insurance market reforms so that people had a chance to meet the mandate. And there is where the common ground has been, on providing people the help they need to get the coverage they want. Our critique has been that the Governor’s plan did not provide sufficient help to many low- and moderate-income populations facing the mandate–and that’s what the negotiations continue to focus on as we speak.

MAKING THE MANDATE MOOT: At the same time, Health Access, in that very same critique and elsewhere, was clear about the fact that we don’t oppose the notion of individual responsibility, whether it’s a payroll tax to finance a single-payer system, or a worker requirement to take-up coverage offered by an employer, as long as it is deemed affordable.

The Democratic presidential plans–by Clinton, Edwards, and Obama, with and without an individual mandate–are in that vein: they largely rely on expanding group coverage, through public programs, employers, or purchasing pools. To the extent that it exists, the individual mandate is incidental, to bring in people and automatically enroll them. Obama actually doesn’t even argue against an individual mandate–he says he would consider it, but only after his plan has provided available, affordable coverage. It seems Clinton and Edwards are there as well, providing assurances to people that coverage won’t be more than a certain percentage of their income.

So is an individual mandate a liberal or conservative idea? Does it matter? People want health coverage–to get the care they need, and to protect them against financial risk. If coverage is available, affordable, and automatic, then the question is moot.

The real issue is what are the policies in place to provide for coverage that is available and affordable for all Americans. That’s what I hope the candidates spend more time debating.

Health Access California promotes quality, affordable health care for all Californians.

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