The Politics of Mandates

I'm a few days late commenting on this, but better late than never. On Friday, toward the end of a column largely devoted to criticizing John McCain’s nonsensical health care policies, Paul Krugman took another swipe Barack Obama:

Indeed, while Mrs. Edwards focused her criticism on Mr. McCain, she also made it clear that she prefers Hillary Clinton’s approach — “Sen. Clinton’s plan is a great plan” — to Barack Obama’s. The Clinton plan closely resembles the plan for universal coverage that John Edwards laid out more than a year ago. By contrast, Mr. Obama offers a watered-down plan that falls short of universality, and it would have higher costs per person covered.

Worse yet, Mr. Obama attacked his Democratic rivals’ health plans using conservative talking points about choice and the evil of having the government tell you what to do. That’s going to make it hard — if he is the nominee — to refute Mr. McCain when he makes similar arguments on behalf of such things as privatizing veterans’ care.

Part of this is fair criticism and part of it isn’t. From a pure policy perspective, I agree with Krugman and Elizabeth Edwards that a health care plan that includes a mandate—like the Clinton and Edwards’ plans—would cover more people and do a marginally better job of reducing overall costs.

That said, I still prefer Obama’s plan. Why? Because I think the inclusion of a mandate would be the death of any health care bill. As Obama has gently tried to point out in this campaign, the only way that a mandate can work is if you impose some sort of penalty on those who do not comply. You have to be ready to impose significant fines on those who refuse to purchase a health care policy.

And that’s the rub. The Republicans don’t need any help coming up with the talking points they’ll need to demonize such a proposal. It will be easy. If you can’t already see the attack ads, you don’t have much of an imagination.

We’re only going to have one shot at getting any kind of comprehensive health care reform through Congress, and that’s only if we’re fortunate enough to have a Democrat take over the White House in January. The pushback against this effort will be intense, with multi-million dollar ad campaigns by independent groups and near universal resistance from the GOP and the conservative media. And while I wish it were not so, I think the inclusion of a mandate would give these groups all the ammunition they need to derail the bill.

I understand why policy wonks like Krugman resent Obama for criticizing something that makes sense from a policy standpoint. I suspect that Obama chose not to include a mandate in his plan precisely because he realized that it was the sort of thing that could sink an otherwise politically feasible bill. Unfortunately, during the course of the primary campaign, he has been forced to defend this decision substantively (rather than just strategically) and has done so by using some of the same arguments conservatives would undoubtedly resort to if the Democrats ever tried to pass a bill that included a mandate.

I think it is perfectly fair to criticize Obama for resorting to such arguments, but that doesn't change the political optics of the situation. Mandates may be good policy, but they are terrible politics. I think Obama’s decision not to include a mandate in his plan will prove to be a wise one if he goes on to be the nominee and an even wiser one if he is eventually elected president and has to undertake the difficult task of actually passing comprehensive health care reform.

There were a lot of features of Clinton's original health care bill that made sense from a policy perspective but were difficult to defend politically. And we know what happened with that bill. Ultimately, the key to accomplishing meaningful health care reform is creating a plan that can survive the political onslaught it will inevitably confront. Once it's passed, and people accept it and want it to succeed, then further bills can be passed to make it more efficient, to help reduce costs, and to help ensure that everyone is covered. But it's going to be an incremental process, and insisting on the inclusion of a mandate strikes me as a way of ensuring that the effort fails, yet again.