Inside National Health Reform

Thursday, September 15, 2011

Welcome to Politics Bites, where every afternoon at It's A Free Country, we bring you the unmissable quotes from the morning's political conversations on WNYC. Today on the Brian Lehrer Show, John E. McDonough, DPH, MPA, professor at Harvard School of Public Health and the first Joan H. Tisch Distinguished Fellow in Public Health at Hunter College, CUNY, discusses his new book, Inside National Health Reform, which takes a close look at the development, passage and enactment of the Affordable Care Act.

The Federal Affordable Health Care Act offered tax breaks to help people afford policies. The Massachusetts Act offered subsidies for insurance coverage for those who cannot pay. Though the first act was commandeered by a Democrat and the second by a Republican, both share a notable element—the individual mandate.

John McDonough helped write both those pieces of legislation. He led the advocacy group “Health Care for All” and has written a new book.  He said that governor Romney proposed the individual mandate as a way to satisfy the Bush administration. Tommy Thompson, the head of the Department of Health and Human Services (DHHS), threatened to withhold the federal government waiver unless the mandate was created.

The state in 2004 was facing the loss of a significant portion of that money [from the waiver], so Governor Romney and the late Senator Kennedy went to the Bush administration arm-in-arm and said let  us hold on to this money, and if you let us… we will create a form of universal health care in one state, tied to an individual mandate, and you, the Bush administration, will get credit for creating universal health care in one state and it won’t cost you anymore than you’re already paying right now.

He clarified that it was not a federal mandate, but a request from Massachusetts for help from the federal administration.  He said it became an agenda item for the administration after that point, and that Bush praised the law through the DHHS.

Romney himself touted the plan as creating competition and options. McDonough said his advocacy group was not enthusiastic about the individual mandate or the entire package.

We had to be drawn to the table. We were very supportive of employer responsibility and very suspicious of individual responsibility.

He said the individual mandate was an idea created and promoted by Conservative policy advocates.

Between the Clinton plan and the Obama plan it was kind of just accepted truth among Conservative circles that the way to address trying to expand coverage was tying it to an individual mandate.

He said it wasn’t until summer of 2009 that the individual mandate underwent a dramatic withdrawal of support from Conservatives.

The value behind Conservative support was.. individual responsibility. .. That it shouldn’t be about big government setting something up, that it shouldn’t be about putting responsibility on others.  Individuals need to take responsibility and we need to create a way for people to be able to buy insurance and then make sure that they actually do so…. The difference was Mitt Romney didn’t just talk about it, Mitt Romney actually did it, and that’s why he’s in such hot water now.

McDonough said premiums continue to go up despite these affordable care acts in part due to the political make up of the policy-makers. In Massachusetts, for example, Romney faced a lot of political opposition from Democrats, which shaped the final form of the act.

He wanted a mandate for much skinner coverage with much higher deductibles and cost sharing.

The act, he said, was not designed to control health care spending but to enforce universal coverage.  Yet the Act does seem to be controlling costs.

Over the last roughly 12 to 15 months, we’ve seen a significant drop in the rate of  increase in the Medicare program.

A large part of that savings has been due to increased crackdown against fraudulent operators.

When a lot of those see that the federal government is getting serious, it actually dissuades people from getting in and committing that type of fraud.

This crackdown seems to be helping move momentum toward a better control of health care costs. McDonough is optimistic that that movement will continue.

There’s not a magic bullet, there’s not a single answer… but I think the news in the years ahead on healthcare spending is going to be significantly better than people are expecting.


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Comments [14]

Yulong Gan from Miami Dade County

Health Policy,
Financial Issues

Oct. 09 2011 07:28 AM
Amy from Manhattan

So why the hell isn't the administration publicizing how much it's saving by going after fraud so aggressively? Seriously, they need to stand up for themselves & tell the voters when they're doing something that's working.

Sep. 16 2011 01:51 AM

Karen -

I know this may be really hard for you to believe but ... I'm an attorney too. I don't teach, I practice. I understood constitutional law when I graduated and I understand it today. But if in fact you are a professor then you should understand why the mandate is unconstitutional.

The constitution, among other things, sets forth limitations on the government. If the decision not to participate in interstate commerce affects interstate commerce to the point that Congress has the authority to regulate it, a premise I reject and one that is self-defeating on its face, then there is no limit on the government's authority. Doubly so in the case of the mandate since a person can't buy interstate health insurance.

I believe you are the one that made the initial assumption that I hadn't read the constituton - am I wrong in that?

Regardless, good luck in your undergraduate class. Just please ... don't perform the tired ritual of liberal indoctrination in higher learning. Let the students make their own minds up. If they use logic and reason they'll find themselves rejecting the authoritarianism that has wedded itself to modern liberal policy.

Sep. 16 2011 12:03 AM
Karen from NYC


I'm an attorney and teach the Constitution in an undergraduate course at a local college. You're making many assumptions about me and many conclusory statements about the health care bill. Many of your conclusions have been rejected by courts that have considered the issue; other courts have disagreed. The health insurance mandate is no more authoritarian than any other form of taxation, including your payroll taxes (which fund social security and Medicare), unemployment insurance (even if you're fortunate enough never to lose a job), school taxes (even if you have no kids). In fact, the mandate is meant to protect, not disadvantage you. It's tragic that people -- including you, apparently -- would rather see millions have no insurance than buy a policy for themselves, or pay a tax to cover their own care if they choose not to do so.

If, assuming that conservatives on the Supreme Court strike down the universal mandate, the health care bill is not also held to be unconstitutional in its entirety (due to lack of a severability clause), Americans will have many health insurance options beginning in 2014. Regardless of whether Obama wins, unless the Republicans gain a super-majority in the Senate, the Bill won't be repealed. I think that even you may find that you like the results.

Have a good evening!

Sep. 15 2011 07:19 PM
Gerald from Urayasu, Japan

The discussion is indicative of how far and fast the GOP continues to swing right. A few years ago, "individual responsibility" meant an individual mandate to buy insurance (which, incidentally, is a "public-private sector" solution and dramatically increases the amount of money going to insurance companies - kind of a "win" for many GOP interest groups). Today, however, "individual responsibility" means each individual being responsible for buying his or her own insurance or just saving up for future disasters or relying of the charity of good neighbors and churches. We've learned this in the recent GOP debates as well as in the article about Ginni Thomas in the New Yorker.

Sep. 15 2011 06:07 PM

And consequently, I don't think it's foolish or crude to suggest that one who argues in favor of the mandate is playing politics. Not you, of course. I'm sure you're just fleshing out the issues.

The bottom line is that no objective reading of the mandate would result in a finding of constitutionality. Reform away, just keep your procedures in check. Our president doesn't seem to think the American people care very much about procedures (his words). I do. It's what protects us from authoritarians.

I'm sure our president could get a lot of "good" done if only that pesky constitution and congress and supreme court weren't in his way.

Sep. 15 2011 01:29 PM

Dear Karen -

Other federal courts have written even more compelling reasons against the mandate.

You can just keep making it up as you go along, if you'd like. I don't mind paying taxes. They pay for our military, roads, schools and even liberal public radio stations. What I don't like is authoritarianism. It seems to me there was a day when those on the left didn't like it either.

Sep. 15 2011 01:14 PM
Karen from NYC

Dear Leaozinho:

I know that you would not be so crude or foolish as to suggest that I am lying, stupid or playing politics; so I expect that you are suggesting that I was wrong in writing that you don't understand the mandate.

Your post (analogy to car insurance) suggested that you believed that, under the mandate, you'd have to purchase insurance. You don't. Sorry that you don't like paying taxes; unfortunately, taxes are the price we pay for living in a civilized society.

Several federal courts believe that the Government's reading of the Constitution is correct. So do I.

Sep. 15 2011 12:42 PM

Hey Karen -

First, I'd beg to argue with you regarding the very premise of your post (please review your first sentence).

Second, the fact that I have to pay a tax does not make the mandate constitutional. It just makes it more repugnant.

Finally, I have read the constitution many times over - your assumptions are as wrong as your politics.

Sep. 15 2011 12:01 PM
Karen from NYC

Dear Leaozinho:

I am neither lying, stupid, nor playing politics. You misunderstand the health care mandate.

Under the mandate, you do not have to purchase health insurance. If you do not have insurance from any source, however -- no Veterans' benefit, private policy, employer policy or Medicaid -- and you choose not to purchase private insurance, you will have to pay a tax, keyed to your income, to cover the cost of the care that you will receive should you, say, get hit by a truck and taken to an emergency room. So, under the Bill, you don't have to buy insurance; if you decide not to, however, you must share the costs of your emergency care, costs that would otherwise be paid entirely by taxpayers.

Nor, as at least two federal courts have held, is this provision "unconstitutional". Congress has the right to impose taxes and regulate inter-state Commerce; the rights of Congress are, in fact, set out Article 1, Section 8 of the Constitution. Section 8 also contains the "necessary and proper" clause, which allows Congress to pass whatever legislation may be necessary to accomplish its enumerated responsibilities.

Since you think that those who make this argument are lying or stupid, perhaps you would like to inform yourself by taking at the Constitution. Below is a link. Good reading!

Sep. 15 2011 11:56 AM
Tony from Canarsie

Very informative interview. Please have Professor McDonough on again.

Sep. 15 2011 11:51 AM
Karen from NYC

No surprise that Romney is a hypocrite and the Affordable Health Care Act a good piece of legislation that will reduce health care costs and help many Americans.

Yet people do not have the facts and don't want to hear them. Rick Perry, I fear, will be our next President.

The American public is never going to vote on facts rather than emotion. Those of us who do are a small minority whose rights and security are being eroded by the majority. Recall that, back in 1789, one of John Madison's arguments in Federalist #10 was that a large republic would guarantee diversity views and avoid minority factions. One of my students pointed out the other day that Madison hadn't anticipated modern media and the internet. Republican propaganda and disinformation have created a version of what Madison feared: "majority factions" that are emotional and misinformed that jeopardize the public interest.

A "contagion" of bad ideas is as devastating as a deadly virus.

Sep. 15 2011 11:48 AM

Brian, pleeeeeeze, ask about how many MA people feel they have bought insurance, but they can't afford to USE IT.

Sep. 15 2011 11:44 AM

I am so fed up with the false equivalency of the federal mandate under the ACA to a mandate to buy auto insurance.

I don't have to own a car. But if I choose to own one then I have to buy insurance for it.

The federal mandate under the ACA is based solely on the fact that I'm an American citizen. Whether you favor health care reform or not the mandate is UNCONSTITUTIONAL. Anyone who says otherwise is lying, stupid, playing politics or all of the above.

Your guest is a professor at Harvard. So I know he knows better and is intentionally misleading in his comments. Shame on him.

Sep. 15 2011 11:41 AM

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