Focused on repeal, GOP struggles to find healthcare mandate alternatives

House Republicans on Wednesday repealed the whole of President’s Obama’s healthcare reform bill – including its individual insurance mandate – for the second time this Congress, but 28 months after the law was enacted, GOP leaders still haven't laid out an alternative plan.

Republicans entered the House majority promising to "repeal and replace" the Affordable Care Act, but so far they've concentrated their efforts on only the first half of that equation. Their reluctance to push specific reform bills has left observers largely in the dark about Republican plans for reining in rising healthcare costs and covering the tens-of-millions of uninsured Americans if their repeal effort ever succeeds.

It's also opened a window for Democrats to attack Republicans – including GOP presidential hopeful Mitt Romney – for bashing the healthcare law without offering concrete plans of their own.

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A key question is how Republicans would fill the void if they eliminate the requirement that everyone buy insurance or pay the government a penalty – the individual mandate requirement the Supreme Court upheld last month by labeling it a tax.

The most controversial provision of the 2010 reform law, that mandate was designed by conservatives decades earlier to rein in "free riders" – uninsured patients who are nonetheless eligible for emergency treatments, piling additional costs onto everyone else.

The mandate has a long history of support from Republicans, who were attracted to the idea that it promotes "personal responsibility." But many Republicans changed their tune as the healthcare reform debate took off in 2009, when they attacked the mandate as a federal assault on individual liberty.

Alex Nguyen, spokesman for Rep. Sander Levin (Mich.), senior Democrat on the Ways and Means Committee, said Democrats adopted the mandate at least partly to attract some GOP support for the reform law. When Republicans pounced on it instead, he added, Democrats "boxed them into a corner" in terms of finding an alternative for addressing uncompensated care, treatment provided without payment.

"They don't really have a plan because we took their idea," Nguyen said Friday.

Robert Blendon, a professor of health policy at Harvard University, said Republicans would have faced much more pressure to push specific healthcare reforms if the Supreme Court had killed the mandate. When the court ruled otherwise, he said, Republicans were free to continue fighting for repeal without the burden of proposing specific alternatives.

"If the court would have struck it down, the press coverage about what to do with pre-existing conditions would have been enormous," Blendon said Friday in a phone interview. When that didn't happen, he added, the debate "sort of lost its focus."

Still, Blendon also cautioned that the lack of specific reforms could haunt Republicans on the campaign trail this year.

"I think some Republican House members are getting nervous that there's nothing in the box, 'What would we do?'" he said.

Republicans have been quick to reject the notion that they don't have any concrete plans for healthcare reform. 

In March, House GOP leaders passed a bill making it harder for patients to sue doctors for malpractice; Speaker John Boehner (R-Ohio) recently promoted the conservative concept of allowing businesses to buy insurance policies across state lines; and House Majority Leader Eric Cantor (R-Va.) noted last month that GOP leaders did introduce a detailed alternative to the Democrats' bill – in 2009.

"We put forward our alternative," Cantor told MSNBC just after the Supreme Court issued its verdict on the mandate. "So to sit here and say we don’t have a replacement is not correct. What we have now, though, is the challenge of repealing this law."

In the 112th Congress, however, GOP leaders have shied away from bringing concrete reforms to the floor, content instead to attack "ObamaCare" while keeping their own reform ideas vague.

The office of Ways and Means Chairman Dave Camp (R-Mich.) did not respond this week to several requests for comment for this story. Questions posed to Boehner's office went similarly unanswered.

The individual mandate concept was churned around health policy shops in the mid-1980s, and picked up by the conservative Heritage Foundation in 1989, when the group released a policy paper advocating that "Americans with sufficient means would no longer be able to be 'free riders' on society by avoiding sensible health insurance expenditures." 

"The requirement to obtain basic insurance would have to be enforced," the paper read. For those who don't comply, it continued, "a fine might be imposed."

Edmund Haislmaier, health policy expert at Heritage, downplayed the significance of that document this week, characterizing it as "a conceptual discussion" the group later abandoned when it came time "to operationalize" the idea. 

He also dismissed the notion that Democrats adopted the mandate primarily to battle uncompensated care, arguing that the law's new restrictions on insurers would lead to premium hikes for younger, healthier patients – folks who tend to be low earners – thereby requiring the mandate to ensure they stay insured.

"The 'free-rider' problem has been exaggerated," Haislmaier said Friday.

But if Heritage had abandoned the mandate before the healthcare reform debate took off, many Republicans didn't get the memo.

Sen. Charles Grassley (Iowa), then the senior Republican on the powerful Finance Committee, endorsed the mandate as late as June 2009, when the healthcare debate was getting underway; four months later, Sen. Olympia Snowe (R-Maine) voted for the mandate as part of the Democratic reform bill passed out of the Finance Committee; and Romney – who adopted the mandate as governor of Massachusetts – was still defending the provision even after the Democrats' bill was law. 

"In my view," Romney said in April 2010, "expecting people who can afford to buy insurance to do so is consistent with personal responsibility, and that's a cornerstone of conservatism.”

Some Republicans are trying to get out ahead of the "replacement" debate, arguing that any such strategy should not be judged by the number of uninsured people it covers. 

Sen. Orrin Hatch (Utah), senior Republican on the Senate Finance Committee, said this week that Congress should instead concentrate on reducing the cost of healthcare services, then shift to focusing on coverage for the uninsured.

"Conservatives cannot allow themselves to be browbeaten for failing to provide the same coverage numbers as ObamaCare," Hatch said Monday during a speech at the American Enterprise Institute. "We cannot address the lack of coverage without addressing the fundamental problem that contributes to the lack of coverage – the high cost of care."

Some observers have accused the Republicans of flip-flopping on the mandate simply because Obama endorsed it. But Blendon, of Harvard University, posed a different theory this week.

"The Republican Party [today] is not the Republican Party that Heritage sold this idea to in the mid-90s," Blendon said. "They opened their arms to libertarians, and … the libertarian wing … is just against mandates."