Meanwhile, even as Democratic stalwarts warmed to the idea in recent years, one of the last holdouts was the man whose political fate is now most closely intertwined with the mandate: President Obama.
“The ironies to this story are endless and everywhere,” said John McDonough, a professor at the Harvard University School of Public Health who, as a Senate Democratic staffer, played a key role in drafting the law.
The tale begins in the late 1980s, when conservative economists such as Mark Pauly, a professor at the University of Pennsylvania’s Wharton School of business, were searching for ways to counter liberal calls for government-sponsored universal health coverage.
“We wanted to find an alternative that was more consistent with market-oriented economic ideas and would involve less government intervention,” Pauly said.
His solution: a system of tax credits to ensure that all Americans could purchase at least bare-bones “catastrophic” coverage.
Pauly then proposed a mandate requiring everyone to obtain this minimum coverage, thus guarding against free-riders: people who refuse to buy insurance and then, in a crisis, receive care whose costs are absorbed by hospitals, the government and other consumers.
Heath policy analysts at the conservative Heritage Foundation, led by Stuart Butler, picked up the idea and began developing it for lawmakers in Congress.
By 1993, when President Bill Clinton was readying his major health-care overhaul bill, the Heritage approach — subsidizing and facilitating the purchase of private health plans, while using the individual mandate to maximize participation — had gelled as the natural Republican alternative.
Then-Sen. John H. Chafee (R-R.I.) formally proposed it in a bill that attracted 20 Republican co-sponsors; the bill foundered once Clinton’s effort unraveled. But the idea of the mandate gained currency in the ensuing years as Democrats chastened by the failure of the Clinton plan began considering new solutions more likely to attract bipartisan support.
The Massachusetts plan
That process came to a head in 2004 when Mitt Romney, then governor of Massachusetts, turned to then-Sen. Edward M. Kennedy (D-Mass.) for help adopting a health-care overhaul for the state that was largely based on providing residents with government subsidies to buy private insurance.
The plan, signed into law in 2006, regulated insurance companies to a degree beyond anything Pauly had envisioned: For instance, they were barred from excluding or charging higher premiums to people with preexisting health conditions.