Uwe Reinhardt, blogging for Economix, writes:

The current, vehement opposition from Republicans to the mandate stuns me. After all, there was a time, in the 1990s, when prominent health-policy analysts allied with Republicans in Congress fully endorsed the idea of the mandate, as did the officeholders whom they advised. For example, in “A Plan for ‘Responsible National Health Insurance,” a seminal paper published in 1991 by a group of politically conservative economists led by Mark Pauly of the University of Pennsylvania, made the mandate a cornerstone of its proposal.
“In our scheme, every person would be required to obtain basic coverage, through either an individual or a family insurance plan,” they wrote. “All basic plans would be required to cover specified health services; plans could, however, offer more generous benefits or supplemental policies. The maximum out-of-pocket expense (stop-loss) permitted would be geared to income, with more complete coverage required for lower-income people, to ensure that no one faced the risk of out-of-pocket expenses that were catastrophic, given their income.”

Pauly has long advocated the use of high-deductible coverage. PPACA is geared towards increasing the use of low-deductible comprehensive insurance plans. My guess is that a mandate for universal catastrophic coverage would have led to higher levels of support from the right. I find it odd that Reinhardt considers this shocking news.

He then identifies a number of Republicans who embraced the Chafee plan:

During the 1990s, prominent Republican members of Congress readily accepted this advice. As Julie Rovner reported on National Public Radio on Feb. 15, 2010: “John Chafee of Rhode Island, along with 20 other G.O.P. senators and Representative Bill Thomas of California, introduced legislation that featured an individual mandate.” She noted that four Republican co-sponsors — Robert Bennett and Orrin Hatch of Utah, Charles Grassley of Iowa, and Christopher Bond of Missouri — remain in the Senate today.

Bennett is indeed in the Senate today, but he was defeated in a Republican primary. Kit Bond is retiring. Grassley might have favored a mandate for universal catastrophic coverage. And Hatch tried to put together a bipartisan proposal that included reductions in the growth of Medicare spending while also enabling states to experiment with coverage expansions, roughly tracking this outline from Douglas Holtz-Eakin:

With appropriate attention to phasing in the policy to avoid disruptions, the exclusion should be eliminated and replaced with a flat credit of $4,500 (indexed for CPI inflation) for those who have private health insurance, regardless of its source. This credit will preserve existing health insurance for those in the employer system and provide incentives for coverage to those outside it.
However, it will not be a panacea. In particular, the credit would not be refundable, so those with no tax liability would require other sources of assistance. As detailed in this paper, for states that sign “Health Insurance for All” (HIA) agreements, the federal government would provide the income-tax resources to each state that was meeting its coverage objectives in proportion to the uninsured population, using sliding-scale, income-based subsidies for private insurance. This would provide additional resources to meet coverage objectives. Also, states should be permitted to allow Medicaid funds to be used for enrollment in private health insurance. Many eligible individuals do not participate in Medicaid because of the personal stigma, an outcome that could be avoided by including private health insurance as an option.

Unfortunately, the first half of Reinhardt’s post is a not terribly interesting exercise in partisan point-scoring. But the second half contains a number of useful ideas, one of which he draws from Sen. Tom Coburn’s alternative health reform proposal:

In his “Patients’ Choice Act” (S.1099), introduced in May 2009, Senator Tom Coburn, Republican of Oklahoma, advocated strictures on health insurers that appear quite similar to those in the health overhaul law. He coupled them not with an outright mandate to be insured but with what he called “auto-enrollment” of individuals in an insurance plan.
Under that arrangement, individuals without health insurance presumably would be automatically assigned to a health plan, but they could either change to another plan or opt out of insurance altogether by explicitly requesting to do so. It is an application of what has come to be called libertarian paternalism or simply “nudging.”

It’s a shame that more conservatives in Congress, and more moderate Democrats, didn’t rally behind PCA.