At the same time, by requiring the private purchase of insurance, the mandate kept the true cost of the health care expansion off the government’s books, and largely out of the Congressional debate. As the Cato Institute’s Michael Cannon has noted, during the Clinton era the Congressional Budget Office scored an individual mandate as a form of government spending, which pushed the official cost of the Clinton bill into the trillions. But the Obama White House was savvier in its mandate design, and the C.B.O. was more compliant in its scoring. As a result, a bill that might require over $2 trillion in new health care spending — private as well as public — over its first decade was sold with a $900 billion price tag.

So the mandate was politically brilliant, in a sense. But its brilliance was evanescent. Founding a new entitlement on an insider-friendly sleight-of-hand made the bill much easier to pass. But it’s made it harder to defend thereafter, both in the court of law and the court of public opinion…

The reality is that the more treatments advanced medicine can offer us (and charge us for), the harder it becomes to guarantee the kind of truly universal, truly comprehensive coverage that liberals have sought for years. The individual mandate conceals these realities, but it doesn’t do away with them. If it’s repealed or swept aside, both left and right might be able to focus on a more plausible goal: not a perfectly universal system, but more modest reforms that would help the hardest-pressed among the uninsured.