“The alliance between Romney and Kennedy was of fundamental importance in terms of creating a level of confidence going into [the] 2008 [presidential elections] that this could actually be the bipartisan path to achieve universal health care in the United States,” he said.
The no-mandate candidate
Indeed, during the 2008 Democratic primary race, candidates Hillary Rodham Clinton, John Edwards and Obama all proposed health-care overhaul plans that shared some features of the Massachusetts system.
But while Clinton and Edwards included an individual mandate, Obama did not (although he did propose requiring parents to get coverage for their children).
Over successive debates and primary battles, Obama hammered the issue as a key difference between himself and Clinton.
“What’s she not telling you about her health-care plan?” said an advertisement for Obama. “It forces everyone to buy insurance, even if you can’t afford it, and you pay a penalty if you don’t.”
“In retrospect, I think Obama had an accurate sense of public opinion about the mandate,” said Paul Starr, a health policy expert at Princeton University, who supports the law but argues that Democrats should have come up with other policies to accomplish the goals of the mandate.
Obama’s views had evolved by December 2008, when, a month after winning the presidential election, he discussed the mandate with former Senate majority leader Thomas A. Daschle (D-S.D.), his nominee for health and human services secretary.
“To my pleasant surprise, the president-elect told us, for the first time, that he might be willing to reconsider his thinking,” Daschle wrote in his book “Getting It Done: How Obama and Congress Finally Broke the Stalemate to Make Way for Health Care Reform.”
The GOP shift
For a while the mandate also retained the support of many prominent Republicans. But as negotiations with Democrats over the health-care bill fell apart in the spring of 2009 — and Republicans spent their August 2009 recess at town hall meetings where furious tea party activists accused them of fomenting a government takeover of health care — positions on the mandate started to shift.
That September, Sen. Charles E. Grassley (R-Iowa), a co-sponsor of the 1993 Chafee bill containing the mandate and a vocal supporter of the idea just three months earlier, declared that “individuals should maintain the freedom to choose whether to purchase health insurance coverage or not.”
During floor debates over the health-care legislation that fall and winter, the mandate took a back seat to more contentious issues relating to abortion, Medicare and the expansion of government regulation.
Still, it continued to build as a political issue after the law’s adoption in 2010, as 27 states began having success with legal challenges largely centered on the mandate’s constitutionality.
Today, opposition to the mandate has become a kind of litmus test of conservative purity. Romney and Gingrich have each struggled, with mixed success, to disavow their former statements in support of it.
Intellectual authors of the idea at the Heritage Foundation have filed legal briefs contesting the mandate and have published mea culpas. “We had made a mistake,” Butler wrote, explaining that “health research and advances in economic analysis have convinced people like me that an insurance mandate isn’t needed to achieve stable, near-universal coverage.”
There is at least one remaining conservative defender: the man who helped start it all, Mark Pauly. He is no fan of the other provisions in 2010 health-care law. Still, he said, when it comes to the mandate, “personally, I think it’s wise public policy.”