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Democrats Differ on Health Care

Mark Twain said that history may not repeat itself, but it surely does rhyme.

“I don’t know anyone who has looked at his plan … who believes it achieves universal coverage.”

“There must be some sort of misunderstanding here. We share the goal of universal coverage. The only question is how we get there.”

Those were first lady Hillary Rodham Clinton’s words, and my response, in 1993. Fifteen years later, Sens. Clinton (D-N.Y.) and Barack Obama (D-Ill.) are having exactly the same debate Democrats were having in the early 1990s. This time, let’s get it right.

The issue, once again, is universal coverage, the single most important domestic policy imperative of the next administration. The question of mandates is not about whether we should have universal health care, but how to require individuals to buy health insurance. This relatively technical issue has been elevated to the forefront of Democratic presidential politics because the health reform plans of Obama and Clinton are similar in other respects.

Once again, Clinton is heavy on big government, forcing everyone to obtain health insurance quickly — at least on paper — and with strict penalties for noncompliance. Obama is lean on mandates except for young people up to age 18, whom he requires to obtain coverage either through school, college or family help. And he would let young people up to age 25 remain on their parents’ insurance. So the difference is really for adults from 26 to 64 (Medicare kicks in at 65). When and how do you require these adults to obtain coverage?

Obama first wants to make health insurance affordable. He thinks that voters are smart and that everyone wants health coverage, but they have trouble paying for overpriced policies in tight family budgets. He wants to drive down health insurance prices using a broad range of government and market disciplines. After a year or two, but before the end of his first term as president, he will decide how much further we need to go in order to achieve universal coverage, taking care of any free-riders or freeloaders who remain. Some type of mandate may be required, but it will be a last resort.

Clinton prefers the clarity, speed and force of employer and individual mandates. This is a very satisfying position for an academic or an omniscient policymaker to have, but it disrespects voters. And it differs from her position in the early 1990s when she realized that individual mandates were too strong. But today she’s for them with a vengeance, particularly since they have been a useful club in the Democratic primary. Hillary has been trying to make Barack look like a wimp on health care.

What’s the real difference? It depends on whether you believe health reform should be bipartisan. Somehow the pundits have missed this elemental question. If you lead with mandates, you are much less likely to have any Republican support in either the House or the Senate. This very flaw wrecked Hillary’s reform plan in 1993. Once her secret, 500- person task force finished their months of work, Hillary’s plan started too far on the left and never reached the middle. It never passed key committees, much less a floor vote, even in a Congress that was heavily controlled by Democrats.

Do we want to try all-Democratic health reform again? If so, history would be repeating itself, complete with the same tragic ending — particularly in a more closely divided Congress. Thomas Jefferson said great initiatives cannot be passed on slender majorities. Anything as personal, as vital, as intimate as health care reform must be acceptable to Democrats, Republicans, independents and other viewpoints. The most important part of any cure is believing that it will work. If you take hope from patients, they are doomed.

Perhaps Republicans, particularly small-business advocates, should not be so belligerent in their opposition to mandates. But they still have a point. When they hear the word “mandate” they see all sticks and no carrots. And guess what? Except for insurance executives, they hate high insurance costs as much as we do. Let’s make them allies, not opponents, in the fight.

Massachusetts is experimenting with mandates right now. People who refuse to buy health insurance are fined $220. We don’t know how many will actually pay the fine, then happily purchase the coverage they refused to buy in the first place. States haven’t been 100 percent effective in requiring car insurance for motorists. A mandate is a hit of thousands of dollars on middle-income families, although for a worthy purpose: their own good. But no one likes the nanny state. Let’s try friendly first.

When Hillary Clinton abandoned bipartisan health care reform in the early 1990s, we lost our best chance until now to achieve universal coverage. If she had chosen to build consensus instead of adopting a defensive bunker mentality, everyone in America would have already had health insurance for many years. We can’t afford to make the same mistake twice.

Rep. Jim Cooper (D-Tenn.), a member of the Budget Committee, is an original co-sponsor of the Healthy Americans Act.

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