The Individual Mandate: A History

Obamacare is finally a reality, and although the name is not necessarily popular, the major provisions of Obamacare actually enjoy wide support among all Americans — including Republicans — except one: The Individual Mandate. The mandate requires that everyone who can afford to, must purchase insurance for themselves, or face fines. The mandate is what keeps people honest and helps fund the entire system. But opposition to the idea of people being forced to buy health insurance has been widespread. Particularly among conservatives who claim that this is an abuse of power that implements a “socialist-style bureaucracy” and that the Founding Fathers would be outraged at this abuse of power.

Is that true? This article attempts to track the history of the individual mandate to find out.

President George Washington

President George Washington

1790 – The very first Congress, which contained no fewer than 20 framers of the Constitution, passed a law that required ship owners to buy medical insurance for their crews. This law was signed by President George Washington.

1792 – Congress passed another statute that required all able-bodied men to buy firearms. While not an insurance mandate, it was definitely a “purchase mandate.” 17 framers were still in Congress. It was also signed by Washington.

1798 – Still with six framers in Congress. They passed a federal law that required seamen to buy hospital insurance for themselves. That’s right: an individual mandate passed by the federal government. Founding Father President John Adams signed it into law.

1989 – The ultra-conservative Heritage Foundation releases the position paper “A National Health System for America” (downloadable in PDF form from their website.) The paper had plenty of horrible ideas in it, such as replacing Medicare with a voucher system, but it also had this gem:

Element #1: Every resident of the U.S. must, by law, be enrolled in an adequate health care plan to cover major health care costs.

This requirement would imply a compact between the U.S. government and its citizens: in return for the government’s accepting an obligation to devise a market-based system guaranteeing access to care and protecting all families from financial distress due to the cost of an illness, each individual must agree to obtain a minimum level of protection. This means that, while government would take on the obligation to find ways of guaranteeing care for those Americans unable to obtain protection in the market, perhaps because of chronic health problems or lack of income, Americans with sufficient means would no longer be able to be “free riders” on society by avoiding sensible health insurance expenditures and relying on others to pay for care in an emergency or in retirement.

Under this arrangement, all households would be required to protect themselves from major medical costs by purchasing health insurance or enrolling in a prepaid health plan. The degree of financial protection can be debated, but the principle of mandatory family protection is central to a universal health care system in America.

Help would be provided in two ways. First, the tax code would be amended, as Chapter 3describes, to give tax relief to individual purchasers of health insurance or prepaid plans and to provide tax credits for out-of-pocket expenses. Second, government would aid those who, because of income or medical condition, find the cost of protection to be an unreasonable burden. Such aid could take the form of vouchers for purchasing insurance or state-managed systems as described in Chapter 5.

The requirement to obtain basic insurance would have to be enforced. The easiest way to monitor compliance might be for households to furnish proof of insurance when they file their tax returns. If a family were to cancel its insurance, the insurer would be required to notify the government. If the family did not enroll in another plan before the first insurance coverage lapsed and did not provide evidence of financial problems, a fine might be imposed.

That’s right. The ultra-conservative Heritage Foundation suggested that we impose an individual mandate for exactly the same reasons that the Obama administration proposed it, a full 20 years before he took office.

1993 – Republicans in the Senate introduced the Health Equity and Access Reform Today Act of 1993, (the HEART Act.) The HEART Act combined insurance vouchers with an individual mandate to force consumers to buy insurance.  Nearly half of the Republican Senate Caucus co-sponsored the bill, including conservative stalwarts John Chafee, Christopher Bond, Bob Dole, Orrin Hatch and others. House majority leader (and soon Speaker of the House) Newt Gingrich is also a huge supporter of individual mandates.

2006 – The Massachusetts health care insurance reform law (informally known as “Romneycare”) is passed and signed into law. It requires that everyone has insurance via an individual mandate. It also creates exchanges for individuals to purchase private insurance; provides subsidies for people who could not afford insurance and prevented insurance companies from denying or cancelling coverage because of pre-existing conditions – all additional components of Obamacare.

The Heritage Foundation sends members to the signing. Newt Gingrich and other conservatives laud the plan as a free-market solution to the health care crisis. Governor Mitt Romney explains why an individual mandate is important.


2009 – On a conference call discussing the President’s health care proposals, Newt Gingrich praises the openness of the process leading up to the bill and reiterates his support of the individual mandate as a free-market solution to the health care crisis.


Obamacare as viewed by the right

Typical representation of Obamacare by conservatives

2010 – The Patient Protection and Affordable Care Act (informally known as Obamacare) is passed into law and signed by President Obama. It contains an individual mandate. The Heritage Foundation, Newt Gingrich, Mitt Romney and the GOP as a whole now deride the individual mandate as a move towards a “socialist-style bureaucracy” and a “government takeover of medicine.”

2012 – In a 5-4 decision, The Supreme Court rules that all portions of Obamacare, including the Individual Mandate, are constitutional. In a surprise move, conservative Bush-appointed Chief Justice John Roberts sided with the more liberal wing of the Court. In the majority opinion, he argued that the mandate was constitutional using the federal government’s power to tax.