1

Introduction:
Over the years, the dire need for the reform of healthcare in the United States has
become increasingly prevalent, and while the situation is by no means new,
solutions still remain in their conception. Proposals have rarely been followed by
implementation, and goals have not seen the commensurate amount of political
force needed to achieve them. Because of this, healthcare reform (or lack thereof)
over the past few decades has encountered difficulties in its ability to make the
move forward or remain dynamic in consideration of new practices, policymakers
from either side unwilling to make the move away from status quo policies together.
The passage of the Patient Protection and Affordable Care Act, otherwise
known as the Affordable Care Act, or Obamacare, constituted a large step in such a
direction. Signed into law March 2010, it represented the most significant piece of
legislation in the reform or regulatory overhaul of the American healthcare system
since the passage and implementation of Medicare and Medicaid under Johnson in
1985. At the core of its provisions was the individual mandate, essentially a
directive for all not covered by employer sponsored health plans, Medicare,
Medicaid, or any other public insurance plan to acquire coverage through private
insurance or pay a penalty fee. The mechanism, at the center of the Democrat-
proposed legislation, quickly evolved into the center of controversy in the
2
Affordable Care Act debate, assailed by Republicans as an attack on freedom
1
among
other things and criticized by others as not liberal enough.
2

The irony of such a dilemma lies in the ideological stances posited by each of
the parties throughout the negotiations. In terms of content, the Affordable Care Act
should have been appealing to Republicans, especially considering a substantial part
of the legislation, the individual mandate, was touted by conservatives before as an
alternative to other approaches favored by liberals.
3
The mandate, adopted as a
measure that would supposedly appeal to the conservative vote would devolve into
one of the most contentious aspects of the healthcare reform debate with both sides
reversing long held positions on the issue at hand. This forms the core of the
investigation: what led to the ideological realignments regarding the individual
mandate in the context of the Affordable Care Act Debate?
Origins of the Individual Mandate:
The concept of the individual mandate was first proposed in a 1989 Heritage
Foundation lecture titled Assuring Affordable Health Care for All Americans. In the
brief, Stuart Butler, the author and health-care expert for the foundation argued for

1
Michael Cooper, Conservatives Sowed Idea of Health Care Mandate, Only to Spurn It Later, New
York Times, February 14, 2012, http://www.nytimes.com/2012/02/15/health/policy/health-care-
mandate-was-first-backed-by-conservatives.html?_r=1&.

2
Harry Enten, The US Healthcare Paradox: We Like the Affordable Care Act But Fear
Obamacare, Guardian, October 1 2013, accessed December 1,
2013, http://www.theguardian.com/commentisfree/2013/oct/01/healthcare-obamacare-
affordable-care-act.

3
Cooper
3
a provision to mandate all households to obtain adequate insurance,
4
upon the
premise of individual responsibility in terms of obtaining healthcare. According to
Butler, Many states now require passengers in automobiles to wear seat-belts for
their own protection. Many others require anybody driving a car to have liability
insurance. But neither the federal government nor any state requires all households
to protect themselves from the potentially catastrophic costs of a serious accident or
illness. Under the Heritage plan, there would be such a requirement.
5
Ultimately,
conservatives and those involved in health care policy alike hoped to increase
efficiency and efficacy of health care in the country and address the ever-present
issue of free-riders, those without insurance intentionally, knowing fully well that
they were guaranteed emergency care from hospitals by law, (the Emergency
Medical Treatment and Active Labor Act passed under Reagan)
6
. The individual
mandate represented the best solution to the issues at hand.
As an Alternative to Other Proposals:
The individual mandate proposed from the 1989 Heritage brief would
constitute the conservative response to the reforms championed by Clinton and
Hillarycare in 1992 and 1993 as well as a basis by which Republicans would build
their own healthcare proposals. Conservatives disliked the monopolizing control of

4
Ezra Klein, Unpopular Mandate, The New Yorker, JUNE 25, 2012, pageNr., accessed December 1,
2013,http://www.newyorker.com/reporting/2012/06/25/120625fa_fact_klein.
5
Klein
6
Avik Roy, The Tortuous History of Conservatives and the Individual Mandate, Forbes, February
07, 2012, accessed December 1,
2013, http://www.forbes.com/sites/theapothecary/2012/02/07/the-tortuous-conservative-
history-of-the-individual-mandate/.

4
the single-payer system, and issues with the idea of the employer mandate made the
individual mandate the more optimal solution to the problems at hand.
7

Hence, the individual mandate presented itself as a market-oriented
alternative to the employer mandate, negating the free-rider quandary by
requiring people to buy insurance while substantially increasing the efficiency of the
healthcare without the higher costs of employer-provided health plans under the
employer mandate. The provision would remain the cornerstone of Republican
health care reform efforts for the next two decades.
8

Development of Democratic Support:
Legislative Support:
After the failure of the Clinton bill and its employer mandate, Democrats
began to look at its Republican alternative, the individual mandate, as a source of
possible compromise. In fact, Clinton even conceded that it represented the best
chance he had at obtaining a bipartisan compromise, regretting his lost opportunity
to establish a direct understanding with [them].
9
The larger trend toward the
model followed as Democrats began endorsing the mandate in their own proposals,
recognizing the fact that it was the best chance of bipartisan support in the search
for a working foundation toward universal health care legislation.

7
Roy
8
Klein
9
Haynes Johnson and David S. Broder, The System: The American Way of Politics at the Breaking Point,
1st ed, (Little, Brown, 1997), pageNr.

5
Executive Support:
With Barack Obamas entrance into the White House, one of the predominant
concerns of the Executive Branch was health care reform. However, Obama himself
was not initially a proponent of the individual mandate that would come to define
one of the major tenets of his landmark Affordable Care Act. In fact, the president
first happen[ed] to be a proponent of a single-payer universal health plan
according to a video from his 2003 campaign for Senate.
10
While his stance and
political logic then were not yet completely refined, Obama still by no means
intended to include a mandate in his vision of health care reform even as he began
his run for the presidency. While most of the candidates in the 2008 Democratic
primaries included the individual requirement in their proposals, his campaign
platform endorsed universal coverage, but not the mandate, countering the plans
produced by the campaigns of Hillary Clinton and John Edwards. The then White
House prospective declared, Elect me, and Ill give you lower costs and let you keep
your freedom.
This strong objection to the individual mandate on the campaign trail would
vanish in about six months into his presidency as he announced his support for the
provision in July 2009 claiming he had changed his mind. When asked in his
interview with CBS, Do you believe that each individual American should be
required to have health insurance? he responded, During the campaign I was
opposed to this idea because my general attitude was the reason people dont have
health insurance is not because people dont want it, its because they cant afford it.

10
Jonathan Cohn, How They Did It, The New Republic, May 21, 2010, accessed December 8,
2013,http://www.newrepublic.com/article/75077/how-they-did-it.

6
And if you make it affordable, then theyll come. I am now in favor of some sort of
individual mandate... The disclosure was more or less a complete reversal of his
stance throughout his campaign.
Two forces in the legislative branch would predominantly push the president
towards the decision: Democrats in the House of Representatives and the Senate as
well as the Congressional Budget Office.
11
Without the support of either one, the
chances of successfully pushing through reform were slim at best.
Given Democrats had already begun to warm to the mandate even before the
president had reached his office, there was not much choice but to include the
option strategically. Both chambers, according to a memo sent to the Oval Office,
were including the individual requirement option,
12
making Obama and his previous
position an outlier in the debate.
13
Either Obama would accept the provision or
would have to continue the fight on his own.
An even more pressing obstacle in the way of Obamas vision of reform he
wished to keep from his campaign was its potential treatment by the Congressional
Budget Office. The same memo from the presidents top health care adviser Nancy-
Ann DeParle noted that the Congressional Budget Office (CBO) [would] likely take
the position that without an individual responsibility requirement, half of the

11
Ryan Lizza, The Mandate Memo: How Obama Changed His Mind, The New Yorker, MARCH 26,
2012, pageNr., accessed December 1,
2013, http://www.newyorker.com/online/blogs/newsdesk/2012/03/the-mandate-memo-how-
obama-changed-his-mind.html.

12
Ann DeParle, Briefing Memo (Washington D.C.: The White House, 2009).

13
Lizza
7
uninsured will be left uncovered.
14
Essentially, without the inclusion of the
individual responsibility requirement, the CBO would score, or frame the bill
proposed in a way that would significantly diminish, if not completely destroy, any
chance of its success. Soon, it was clear Obama was left without much choice but to
abandon the anti-mandate stance he had defended during the presidential race.
Implications:
After the failure of the employer mandate under Clinton, Democrats began
looking for other measures that could possibly guarantee passage of successful
reform legislation. This would lead them to the individual mandate, an idea they had
refused to consider earlier, but an alternative that could potentially drive a
successful passage. Democrats, recognizing the need to more or less force the bill
through the legislative process, were willing to look to the mandate as their
bipartisan solution. Soon enough, the party, long resistant to the individual
requirement option, became its strongest defenders.
The Executive Branchs relationship with the individual mandate in this
process was one defined by change (the namesake that also defined its leaders
campaign). But this change was one characterized by an impermanence of the
stances presented by the campaign and by the administration, even the ones most
adamantly upheld. In fact, Obamas opposition to the mandate built a large part of
his campaign platform that brought him to the White House. However, when faced
with the political realities of the work ahead, Obama was forced to recant the
position he had once firmly stood by in his campaign. Whether the shift was based

14
DeParle
8
on political maneuvering or perhaps various groups forcing Obamas hand, the
American people would vote for a candidate who strongly opposed the mandate, but
would get a president who strongly favored one.
15
The individual mandate would
soon become one of the Obama Administrations top legislative priorities, defining
its health care policy goals in the process that would finally come to the realization
of health-coverage reform in the Affordable Care Act. The provision itself would
quickly become one of the most hotly debated topics in the fight despite its only
lukewarm support from the White House in the beginning of the development of the
legislation. The president ultimately came to view the debate as a proxy for a deeper
question that plagued American politics, a test as to whether the nation could still
solve its most pervasive, vexing issues.
16
For the sake of resolving the health care
reform question that had plagued the country for decades, he, as well as the
members of his party, needed to find viable options regardless of ideological
discrepancies.
Withdrawal of Conservative Support:
Legislative Opposition:
The fact that many prominent members of the Republican Party supported
the idea of the individual mandate did not, by any stretch, mean all Conservatives
were pro-mandate. There still remained an intra-conservative divide between those
that were pro-mandate and those that were opposed to the measure even at the

15
Andrew Cline, How Obama Broke His Promise On Individual Mandates, The Atlantic, June 29,
2012, accessed December 1, 2013, http://www.theatlantic.com/politics/archive/2012/06/how-
obama-broke-his-promise-on-individual-mandates/259183/.

16
Cohn
9
height of its popularity.
17
These camps would last until 2009
18
when the rise of the
Affordable Care Act and the debate over the actualization of health care reform in
the United States would quite suddenly move almost all conservatives and
Republicans into the anti-mandate camp. In December 2009, as voting began on the
legislation, every Senate Republican would vote against the bill, calling the
individual mandate unconstitutional. The mandate to them was not only
inappropriate policy, but (to an even more extreme degree) also contrary to the
wishes of the Founders.
19

As Republicans began to withdraw their support, even those responsible for
the origins of the concept of the individual responsibility requirement for health
care would retract their backing as well. In October of 2011, Stuart Butler from the
Heritage Foundation, who first introduced the idea of the mandate, published an op-
ed for USA Today that recanted his as well as the organizations support.
20
Butlers
voice in the article was fairly clear as he stated, Ive altered my view on many
thingsmake no mistake, Heritage and I actively oppose the individual mandate.
21

The mandates founders did not only retract their position, but even went as far as
to say the notion that Butler or Heritage had invented the concept was a myth.
22

Other senators would follow, even those who had proposed similar pieces of
legislation also voicing their discontent with the mechanism of the Affordable Care

17
Roy
18
Roy
19
Klein
20
Roy
21
Stuart Butler, Don't Blame Heritage for Obamacare Mandate, USA Today, February 6, 2012,
accessed December 8, 2013, http://usatoday30.usatoday.com/news/opinion/forum/story/2012-02-
03/health-individual-mandate-reform-heritage/52951140/1.

22
Roy
10
Act. Senator Orrin Hatch, one of the co-sponsers of the mandate alternative to
Hillarycare would write that to accept the provision would mean only, treating the
Constitution as the servant, rather than the master, of Congress.
23

Opposition would remain unanimous as all Republicans in the Senate and in
the House of Representatives would vote against the passage of the Patient
Protection and Affordable Care Act. The Senate bill and its mandate would pass in
the House on a 219-212 vote, with all 178 Republicans against it along with 34
Democrats. From such a large base of support in its beginnings, the individual
mandate would face a unified opposition from the same ideological partners it had
only a decade or so before.
Implications:
Despite the active support the individual mandate had received from a number of
Republicans when it was proposed, it quite suddenly became a point of huge
resistance in the health care reform debate. As the development of the Affordable
Care Act continued forward, Republicans would begin coalescing around the
mandate,
24
labeling it as socialist totalitarianism
25
among other things. The once
conservative idea and proposal would come to garner some of the strongest
opposition among the Republican base.

23
Orrin Hatch, The Individual Mandate Is Unconstitutional, The Hill, December 16, 2010, accessed
December 8, 2013, http://thehill.com/blogs/congress-blog/healthcare/133985-the-individual-
mandate-is-unconstitutional-sen-orrin-hatch.

24
Klein
25
Cooper
11
Judicial Battle:
Soon after the passage of the Affordable Care Act opponents of the new law
attacked it, challenging the mandate mechanism of the bill, requiring Americans to
purchase health insurance or face penalties, as an unconstitutional overreach.
Twenty-eight states in total would file lawsuits against the legislation, twenty-six
jointly, including Florida, South Carolina, Alabama, Nebraska, Texas, Pennsylvania,
Michigan, Washington, Utah, Idaho, Colorado, North Dakota, and South Dakota, that
filed a mere seven minutes after President Obama signed it into law.
26
The
individual mandate of the bill, which requires the purchase of health insurance by
each person supposedly overstepped Congresss constitutional power to regulate
commerceamong the several states beyond reasonable federal authority.
The landmark health care reform bill had already weathered passage
through the legislative houses. However, the fight was by no means over. The
ensuing legal battle that followed would bring political controversy right back to the
act and its mandate that would have to appeal to a court as it had done in the House
of Representatives and the Senate.
Republican Side:
Within minutes after Obama signed the Affordable Care Act into law,
attorneys general from thirteen different states moved to file lawsuit in Florida. All
except James Caldwell of Louisiana were Republican. Legal experts agreed the
movement had little chance of success; however, the attorneys general were
adamant in building their case.

26
Associated Press, 13 Attorneys General Sue Over Health Care Overhaul, USA Today, March 23,
2010, accessed December 8, 2013, http://usatoday30.usatoday.com/news/nation/2010-03-23-
attorneys-general-health-suit_N.htm.

12
Florida Attorney General Bill McCollom, who championed the lawsuit for
weeks, spearheaded the effort, calling other states to join him in challenging the bill
that would cause, substantial harm and financial burden to the states. This
challenge was necessary since, according to Virginia Attorney General Ken
Cuccinelli, the law will force citizens to buy health insurance, claiming it has the
authority to do so because of its power to regulate commerceif a person decides
not to buy health insurance, that person by definition is not engaging in
commerce, and therefore not subject to a federal mandate. Again, the mandate
would be at the center of Republican opposition, this time, in the courtroom.
Despite the fact that the chances of the Affordable Care Act being overturned
were slim at best, Republicans were able to consolidate a platform from their
position against it. The legal fight against the constitutionality of the measure gave
conservatives clout in the argument as the media picked up the fight and brought it
to a wider audience through its coverage. As Republicans made the opposition to the
mandate their position, the conservative media would make it their standard
position as well. The endless stream of coverage and repeated explanation of the
stance would legitimize the arguments by virtue of media coverage. Taking such a
loud stand against the mandate, no matter what the chances it had in court, gave
Republicans not only a platform for their positions, but also could amplify the
resistance that had already existed for the mandate and build a coalition around that
discontent. Even if the mandate would inevitably be upheld as law, the party would
not go down without a fight.
13
Democratic Side:
In order to win the legal battle that was mounting against their legislation,
Democrats and the Obama administration would have to change their interpretation
of the function of the mandate. The White House initially recognized the individual
mandate as a requirement to comply with the law,
27
not a tax as Republicans
claimed during the debate. Basically, people would be required to purchase health
insurance as per the Affordable Care Act or pay a penalty.
The provision began as its namesake, a mandate for individuals to purchase
insurance. This served to combat the Republicans strong objection to it as, what
they claimed, was a tax. After the law was challenged in court, however, the
administration would suddenly shift arguments. The mandate was now also a tax as
well as a mandate. The Supreme Court ultimately upheld the law on a 5-4 decision,
declaring the penalty was a valid and constitutional exercise of the Congressional
power of taxation, as proponents of the bill argued. However, if the justification for
upholding the law fell solely under the Commerce Clause, then the law would not
have been upheld. After the courts finished voting, the administration would shift its
stance again, all in agreement with the courts ruling.
Implications:
The political controversy of the individual mandate would not stay contained
in the legislative fight, but would spill over into the judicial branch as well. Each side
would take positions strategically, unafraid to completely change them one way or

27
Jesse Lee, Word from the White House: Common Ground On Health Insurance Reform, The White
House Blog, September 29, 2009, accessed December 8,
2013, http://www.whitehouse.gov/blog/2009/09/29/word-white-house-common-ground-health-
insurance-reform-real-health-care-tax.

14
another, prompting some to even call the Washington D.C. relationship with the
mandate truly schizophrenic
28

The polarization of the individual mandate debate became especially
apparent when it found its way into the Supreme Court. Republican resistance was
built off not necessarily the contents of the debate but rather the need to magnify
the strength and volume at which their stances were heard. With such tactics, even
the courts were not as far from the politics as what people may have assumed, as the
supposedly unfeasible effort by the Republicans actually garnered some support
from conservative judges, which only further compounded the media frenzy that
had already ensued over the issue. Any decision in the Republicans favor would
draw even more attention to the party.
While the Republicans stuck to the ideological stance they had taken on the
mandate (nevertheless still a reversal of the stance they had taken historically), the
Obama administration and Democrats would shift their interpretations of the
meaning of the mandate in the Affordable Care Act to guarantee a win for their
legislation. The administration would utilize this strategy hoping if the courts struck
down one position, the other would remain upheld.
The legal battle over the constitutionality of the individual requirement portion
would prove the administration was willing to switch its positions readily even after
they had been supposedly finalized. Democrats would hail the ruling as a victory for
the president; however, the win would not have been possible if Obama had not

28
Klein
15
consistently deployed the strategy of shifting the positions he and his
administration stood by throughout the debate
29
.
Motivated Reasoning:
The sudden reversal of support for the individual mandate was by no means
an isolated case.
30
In 2007, both John McCain and Newt Gingrich would be
proponents of cap and trade programs as a solution to lowering emissions and
stemming the progress of climate change. Today, neither the two nor the rest of the
Republican Party no longer support any cap and trade initiatives. In the same lieu,
Republicans refuse to support deficit-financed stimulus even after the Bush
administration pushed through the Economic Stimulus Act in 2008, a deficit-
financed tax cut to help the flagging economy.
31
Obama would also, conversely,
warm to the individual mandate despite being firmly against throughout his
campaign and before he entered the White House.
In theory, people join with political parties based on how similarly the group
aligns with their values and goals. Given citizens and elected officials must make
judgments on a diverse and complex set of issues, parties help, or at least attempt to
help develop an organized way by which people can navigate these issues.
32

However, parties, though based in certain sets of principles, are still entities
interested in increasing political capital, or power. Such motivations can manifest
themselves in the commitments (or lack thereof), to certain positions.

29
Cline
30
Klein
31
Klein
32
Klein
16
Decisions made regarding support or opposition to the mandate came down
to what psychologists call motivated reasoning, otherwise, loyalty to the party.
33

Rather than focus upon the content of each proposal, Republicans and Democrats
alike would join whatever side their party positioned itself with. However, the
motivations for taking whichever side was offered was based on the need to either
obtain a win for the party or take away any chance of victory for the other side.
Ultimately, in the case of the individual mandate, liberals and conservatives alike,
the group supporting the policy overrode information regarding the policys actual
content. Ideology was malleable depending on whichever situation would point
success in either partys direction.
Conclusion:
The passage of the Patient Protection and Affordable Care Act on March 21,
2010 represented arguably the largest regulatory overhaul of the American health
care system as well as a huge legislative milestone for the Obama Administration.
The Acts success was not only a victory for the president and the Democrats, but
was also the promise of a move toward better quality and efficiency of care,
accompanied by lowered costs.
The individual mandate that constituted one of the major tenets of the Act
was an effort by Democrats to consider a bipartisan solution in order to push
through the legislation and resolve a national issue of long time interest to the party,
health care reform. However, the mandate would quickly become one of the most

33
Klein
17
controversial issues in the debates that would precede and follow the passage of the
Affordable Care Act. The irony of the conflict resided in the fact both sides would
end up taking the exact opposite position each would align with historically:
Republicans opposing the provision that they had created and endorsed for decades,
and Democrats including the option they initially refused to even consider. When
asking what led to such ideological realignment, the answer comes down to what
represented the most favorable options for each party involved. Each side would
inevitably endorse a position that could provide them with a win, and the sides that
were formed had little to do with the significance of the actual contents of the policy
involved. Whatever the motives of each member or each group, the end result would
be the same across the board; party loyalty would trump almost any other factors in
ideological alignment.



















18


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