Governor Mitt Romney is just four years too late. If he had beaten Senator McCain for the 2008 Republican nomination, the individual mandate would have been front and center in his campaign; a ‘make the trains run on time’ corporatist approach to pooling health insurance risk that could save the country from the wild-eyed liberal schemes that Senator Obama would surely impose, yada yada. I am sure Gov. Romney would have taken tremendous glee in saying something like this over and over: “even Hillary Clinton has embraced the individual mandate that we successfully implemented in Massachusetts; only Senator Obama remains committed to a government takeover of health care that was rejected when Hillarycare was defeated.”

Of course, the ACA (aka Obamacare) with the individual mandate front and center came to not only be called a government takeover, but an assault on liberty and freedom itself. The Supreme Court will have their say in a few days, but it is worth asking what do the flip flops on the individual mandate mean more broadly?

The President did attack the individual mandate during Democratic primary, and it was about the only substantive issue that was different between the President and Sec. Clinton. However, in choosing to support the individual mandate he choose to embrace a practical strategy to pool risk that appeared to have bipartisan support and could therefore be passed. In doing so, the President demonstrated the commitment of progressives and their most closely allied political party to move toward universal coverage, even if it couldn’t be totally achieved in the ACA.

Conservatives, and their most closely allied party, the Republicans, showed that they have no overriding vision for health reform by their widespread flip flop on what had long been the conservative, responsible way to achieve reform. They have many ideas, but they are mostly used to argue against the advances of the other side. In short, they are great on defense, but seem to have no offense. Offense implies having an overall grand vision for health care, and a practical strategy to move toward this vision that includes the willingness to use political capital to achieve large or small victories moving toward an overall goal. The overarching vision for progressives is universal coverage. For conservatives, I have no idea what it is. Do you?

This isn’t just a health care issue. The overarching political question of our day is how to develop a sustainable federal budget over the long term, while determining what policies are most conducive to short term economic growth.

There are two requirements to ever having anything near a balanced budget in the long run: an increase in taxes over historical levels, and some way of slowing health care cost inflation while also dealing with coverage and quality issues. The Democratic party and progressives are not perfect, but they have generally embraced the first and passed a beginning step toward the second in the ACA (first step, not the last). Republicans remain committed to further tax cuts, and still are not sure what they are for in health reform. This means they have no practical hope of achieving the policy outcome they claim to most want–a balanced budget. Cutting discretionary spending, no matter how painful, can’t get you there.

The Republican party may be on the cusp of a partial or complete short term political victory on health reform. In the long term, they are more likely to be the dog that catches the car. They need a deal on health reform terribly, and seem to be the last to know.

[Cross-posted at The Reality-based Community]

Don Taylor

Don Taylor is an associate professor of public policy at Duke University, where his teaching and research focuses on health policy.