Is Health Mandate Liberal or Conservative?

It may not matter whether the individual health insurance mandate is liberal or conversation. What matters is whether it cuts or raises health care costs.Following the U.S. Supreme Court's somewhat surprising ruling to uphold the Affordable Care Act, discussion now centers on a political verdict this November. Presumptive GOP presidential nominee Mitt Romney says he will recommend repeal on his first day in office.

If Romney has Republican majorities in the U.S. House and Senate, he may get his wish. The GOP majority in the House is voting today for the 31st time to repeal the act, which is a non-starter in the Democratically controlled Senate.

The venom over ObamaCare voiced in talk show commentary, letters to the editor and Republican speeches seems oddly out of touch with the history of the Act's most controversial provision — the individual health insurance mandate.

The idea emerged from the Heritage Foundation in 1989, which linked the mandate to its conservative political philosophy of individual responsibility. Early supporters included Utah Senator Orrin Hatch and then-Massachusetts Governor Mitt Romney. The 2006 Massachusetts universal health care law includes an individual health insurance mandate.

San Francisco Chronicle writer Debbie Saunders commented, "Mitt Romney, the former Massachusetts governor, the party’s all-but-certain nominee, is the only Republican in the country who imposed a health care plan with an individual mandate on his state. Romney used to call the provision 'the ultimate conservative idea,' as it told citizens that they’d get government help only if they couldn’t afford to take care of themselves. Team Obama is so smitten with Romney’s past that White House aides often credit Romney with coming up with the template for ObamaCare."

So how did an idea with such strong conservative appeal turn into anathema among conservatives? Ezra Klein, writing in The New Yorker, attributed it to politics. Republicans hated to see Obama score a major political victory.

However, a deeper analysis suggests many Republicans — and a fair number of Democrats — grew worried that achieving universal access without significant health care cost controls would push the price of health care up, not down. The Los Angeles Times reported in 2009 that the individual health care mandate without cost controls would "add up to higher costs for taxpayers and consumers."

The cost of health care is a concern shared widely over the political spectrum. It is likely to become the next battleground, regardless of whether the Affordable Care Act remains in place or not.

Because Oregon chose to get in front of events, not react to them, it is poised to launch a form of cost control in what are called Coordinated Care Organizations, intended to make health care delivery more efficient and based on outcomes, not procedures. It may not actually control costs, but it will put the hard decisions about care, benefits and reimbursement in local hands.

Oregon also is ready to launch a health insurance exchange to provide a shopping mart for health insurance plans that can meet the needs of differently situated families and businesses.

These most likely won't be enough to ward off rising health care costs, creating more intense political pressure as state Medicaid enrollments are expanded. This portends the real political fronts that matter won't be in Congress or the Supreme Court, but in the management circles of local health care delivery systems, which will need to do more to prevent illness and streamline treatment for people who are sick or injured.

Paradigms will need to shift. (NPR carried a story this week about hospitals with cafeterias run by fast food restaurant chains that offer high-calorie menu items.) More fresh ideas and experiments will be needed. They won't be liberal or conservative. They should be judged only on the basis of whether they provide quality care at an affordable price. Somehow that message hasn't penetrated through the thick cloud of partisan rhetoric over the Affordable Care Act.