A Conservative Case for Obamacare?
Are the individual mandate and health-insurance exchanges conservative ideas?


J. D. Kleinke, my neighbor at the American Enterprise Institute, has written a New York Times op-ed that recycles a fact-challenged rewriting of health-policy history and combines flawed analysis with wishful thinking.

Kleinke argues that the individual mandate and health exchanges of the Affordable Care Act (ACA) were, and should remain, sound conservative ideas meriting Republican support. He imagines that, but for crass political calculations, Republican leaders would be taking credit for what President Obama borrowed from them.


To borrow the words of former president Clinton during another Obama-related political battle four years ago, “Give me a break. This whole thing is the biggest fairy tale I’ve ever seen.”

Dismantling Kleinke’s argument will require:

coming to terms with the dalliance of a handful of Republican-affiliated figures with the individual mandate as a politically expedient defensive measure — two decades ago;

understanding how grassroots conservatives have a better instinctive handle on health-policy issues than many of their timid, would-be “leaders”;

seeing how the ACA’s health exchanges are designed primarily for heavy-handed government regulation and income redistribution rather than for choice and competition in health insurance;

acknowledging the serious mistakes of Romneycare in Massachusetts but ensuring they don’t have to be repeated exponentially on a national basis; and

moving beyond the thin rhetorical slices of conservative health-policy reform ideas toward more substantive “repeal and replace” details that can offer realistic hope and deliver sustainable change.  

The Paternity Test for the Individual Mandate
I remember receiving, back in 1989, one of the Heritage Foundation’s earliest briefings on the idea of a mandate requiring individuals to purchase health insurance. To the extent that any conservatives were paying attention to health policy back then, it was not broadly welcomed on the right. In 1991, AEI published a mandate-based proposal for “Responsible National Health Insurance.” It was developed by four right-leaning health-policy analysts who gave it their best shot in an unfavorable political climate. In the early fall of 1993, most Capitol Hill Republicans were discouraged by the apparent popularity of the first wave of the Clinton plan. The response of roughly half of the Senate Republicans was to co-sponsor an alternative bill offered by Senator John Chafee that included an individual mandate. And about as many Senate Republicans (with some overlap) co-sponsored another pro-mandate bill advanced by Senator Don Nickles and essentially designed by the Heritage Foundation’s health-policy team.

But then-senator Phil Gramm, along with Bill Kristol’s Project for the Republican Future, rallied the troops. Almost all other conservative policy groups (such as the Cato Institute, the National Center for Policy Analysis, the Manhattan Institute, the Competitive Enterprise Institute, Citizens for a Sound Economy — a forerunner of FreedomWorks — and even parts of AEI) joined in, along with even stronger grassroots sentiment, against Hillarycare part I. I don’t recall running into J. D. Kleinke at any of those meetings planning how to stop the Health Security Act, or his writing any papers for, or against, the Heritage-sponsored individual-mandate alternative that by the spring of 1994 was abandoned by most Capitol Hill Republicans.

From that time until President Obama took office, few elected Republicans supported the idea of an individual mandate. Why? Because they had learned that leaders need followers, and the mandate was vigorously opposed by conservatives around the country. Even the Heritage Foundation eventually found its way back to the front lines of opposition.

The rebuke from the grassroots
In contrast with the strong resistance that the Clinton plan met from the health-care industry in 1994, a divide-and-conquer strategy by the Obama White House and its allies kept most of the key industry players at the table, hoping for scraps or even some early-bird specials at the subsidy buffet line. Consequently, the first significant signs of opposition to Obamacare came from outside the Beltway at the grassroots level, during the summer recess of 2009.

Capitol Hill Republicans became more emboldened to oppose Obamacare when they learned that it was more unpopular than they had imagined. This is not to ignore the important roles of a handful of Hill Republican leaders, but the ACA would not have been held up until March 2010, after narrowly escaping several near-death experiences, without the strong signal originating from outside of Washington, primarily from many less-traditional activist groups. 

We ignore at our peril the lesson that the most principled and politically effective, if not particularly sophisticated, signals on health policy (and other issues) don’t usually start in Washington.


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