RENEE MONTAGNE, host:
And when it comes to health care bill, one of the biggest issues dividing Democrats and Republicans, is whether everyone should be required to have health insurance. Most Democrats say they should, Republicans disagree.
But as NPRs Julie Rovner reports, that wasnt always the case.
JULIE ROVNER: For months now, Republicans have been hammering away at the proposed requirement that every American have health insurance. Here was Utah Republican Orrin Hatch, during the Senate floor debate in December.
Senator ORRIN HATCH (Republican, Utah): Congress has never crossed the line between regulating what people choose to do and ordering them to do it. The difference between regulating and requiring is liberty.
ROVNER: And here is Iowas Chuck Grassley during the Senate Finance Committees consideration of the measure, last fall.
Senator CHUCK GRASSLEY (Republican, Iowa): For the first time in the history of our country - 225 years - the federal government saying, you have got to buy something. Thats never been before.
ROVNER: Their opposition to making health insurance mandatory, however, is ironic. The last time a major health overhaul was debated when Bill Clinton was president, the Republican alternative bill featured the exact requirement both senators are now berating, and both Hatch and Grassley were co-sponsors of that bill. So whats changed since then: politics, mostly.
Len Nichols of the New America Foundation says the individual mandate was actually created by Republicans and only later embraced by Democrats.
Dr. LEN NICHOLS (Health Policy Program, New America Foundation): It was invented by Mark Pauly to give to George Bush, Senior, back in the day, as a competition for the employer mandate focus of the Democrats at the time.
ROVNER: He is referring to health economist Mark Pauly of the Wharton School at the University of Pennsylvania. Pauly says it wasnt him alone, he was actually part of a small group of conservative health economists and lawyers who cooked up the idea in the late 1980s.
Dr. MARK PAULY (Chairman, Health Care Systems Department, Wharton School): In some ways it was kind of like a Judy Garland/Mickey Rooney movie.
ROVNER: Except instead of putting on a show...
Dr. PAULY: A group of economists and health policy people, market-oriented, sat down and said, let's see if we can come up with a health reform proposal that would preserve a role for markets, but would also achieve universal coverage. And I think the individual mandate was derived, mostly, from the power of logic.
ROVNER: That logic being that even the most generous subsidies or enticements, he says, could only get you so far.
Dr. PAULY: There'd always be some Evel Knievels of health insurance, who would decline coverage, even if the subsidies were very generous, even if they could afford it, quote unquote, "if you really wanted to close the gap, that's the step you would have to take."
ROVNER: Now one of the key justifications for requiring everyone to have at least catastrophic health insurance is what economists call the Free-Rider Effect. If you're in an accident or you come down with a dread disease, you're going to get taken to the hospital and someone's going to pay. And that was something that appealed to Republicans, at least back then, says Pauly.
Dr. PAULY: We called this responsible national health insurance, so there was a kind of an ethical and moral support for the notion that people shouldn't be allowed to free-ride on the charity of their fellow citizens.
ROVNER: Now the Republican bill introduced in 1993 did differ in some substantial ways from the bills now pending in Congress. For example, that bill included caps on damage awards in medical practice lawsuits, which the Democrats' bills dont.
But the bills also have tremendous amounts in common. The Republican bill from 1993 also called for purchasing cooperatives, similar to the Democrats' health exchanges. And the Republican bills even propose to boost federal research on how effective medical interventions are; thats another effort Republicans have recently criticized.
Len Nichols, of the New America Foundation, says he's depressed that so many issues that used to be part of the Republican health agenda are now being rejected by Republican leaders and most of the rank and file.
Dr. NICHOLS: I think it really is a sad testament to the state of relations among the parties that they've gotten to this point.
And how does economist Pauly feel about the GOP's retreat from the individual mandate they used to promote?
Dr. PAULY: That's not something that makes me particularly happy.
ROVNER: Nor, does it make happy, those who are still hoping for a bipartisan solution to the health care problem.
Julie Rovner, NPR News, Washington.
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