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The Parable of the S. S. Independent Mandate

Posted by John McDonough  March 26, 2012 10:15 AM

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So, here we are, the Affordable Care Act (aka: ACA) and the Supreme Court of the US (aka: SCOTUS). For public health law and political junkies, this is the World Series. Six hours, three days. Every move and statement will be parsed and analyzed. It doesn't get better than this.

And while interest is high among non-policy wonks, let's recognize vast confusion among the broader public. Broccoli, home grown wheat, home grown marijuana, car insurance, huh?  So, as a public service to those who might like to get up to speed, I offer a modern day parable on the ACA's biggest controversy, the individual mandate.

Like any good parable, it starts with an oversized metaphor: so, imagine a sailing ship called the S. S. Individual Mandate.

The idea for the SSIM began in the late 1980s, the brainchild of a UPenn health economist named Mark Pauly. He was fond of capes, and wrapped his idea as an to those who argued that getting to universal health insurance required a public mechanism, such as those in Canada or Great Britain. Pauly talked up his idea around the docks, and found an ally in the conservative Heritage Foundation. The appeal, to some, was instantaneous -- a way to universal health insurance relying on private health insurance and personal responsibility.

When Bill and Hillary Clinton in 1993 tried enact a private health insurance path to universal coverage relying on a mandate on employers to provide insurance for their workers and families, Pauly and Heritage got many Republicans on the docks to swarm to their idea as an alternative to the Clinton approach. One early champion, the pirate Newt Gingrich, now says publicly he only embraced the idea to thwart the Clinton's.

After the Clinton's retreat, Republicans brought out their individual mandate drawings whenever a conversation turned to universal coverage. Occasionally, a stray Democrat such as Sen. John Breaux (D-LA) would embrace the idea, never getting much traction. And when Republicans controlled the White House, House, and Senate between 2001 and 2006, they never pushed to adopt their scheme as a national law. Never a bill or a vote.

Things changed dramatically when a rascal Republican named Mitt Romney decided to build his own boat based individual mandate drawings to use in the waters of Massachusetts. Shockingly, Democrat Ted Kennedy joined him on the boat. This was a big deal. No one in the nation was more identified with universal health insurance than Kennedy, and he embraced Romney's design with gusto, hoping it might even go national. With Kennedy seated high on the deck with Romney, Democrats decided to climb on board to check out the view, and many liked what they saw.

Then, Rascal Romney did something no one in the whole nation had ever done. See, in the 15 years before then, Republicans and conservatives only had drawings to show, nothing real. Romney, after designing and building the boat, took it out for a sail. And despite the predictions by the Wall Street Journal and others that the boat would sink, it floated, with Romney at the steering wheel waving and smiling at anyone and everyone who looked his way. Even buccaneers such as South Carolina's Senator Jim DeMint endorsed Romney and said the ship should be a model for the nation.

With Kennedy on deck, more Democrats came aboard, agreeing that this was a pragmatic voyage to universal health insurance. Presidential candidates Hillary Clinton and John Edwards endorsed the ship as stories began showing that the Massachusetts boat could sail. Would-be Admiral Barack Obama was reluctant and would not endorse the model, except for children. Then in 2009, Democrats got serious about designing and building their national SSIM, and the boat deck started getting seriously crowded. Then, in June, the ship got nearly mobbed when Admiral Barack Obama finally hit the deck.

Though as more and more Democrats climbed up the bridge, Republicans began to jump over the rail on the other side of the boat, into lifeboats, into dinghies, or just into the water to swim ashore. Within months, there was hardly a Republican left on the boat.  Back on shore, many Republicans denied ever having stepped foot on the boat.

With one exception.

That Rascal Mitt Romney had been photographed repeatedly at the wheel steering the ship, and standing and smiling with Ted Kennedy. He was even videotaped urging everyone to come aboard. It was tough for him. The photo signing the Massachusetts ship into law, seated next to a smiling, standing Kennedy was impossible to deny. So he didn't. Instead, he claimed that the D.C. designers of the new boat messed up the plans and what looked like the Massachusetts version, really didn't resemble it at all. Sure, both boats included the same essential features and looked similar, but Rascal Mitt tried and tried to let everyone know they weren't the same.

Over time, it became impossible to find a Republican anywhere who wanted anything to do with the S.S.I.M. -- even the Heritage Foundation backed as far away as they could without falling off the edge of the world. Republican state Attorneys General sued to dismantle the ship, calling for the SCOTUS to seize it.

And then SCOTUS surprised everyone by ... (to be continued)

And the moral is: be careful what you wish for, because you just might get it.

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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