History of the Individual Health Insurance Mandate, 1989-2010
Republican Origins of Democratic Health Care Provision


Heritage Foundation's 1989 report is considered to be the conceptual origin of the health insurance mandate.
The concept of the individual health insurance mandate is considered to have originated in 1989 at the conservative Heritage Foundation. In 1993, Republicans twice introduced health care bills that contained an individual health insurance mandate. Advocates for those bills included prominent Republicans who today oppose the mandate including Orrin Hatch (R-UT), Charles Grassley (R-IA), Robert Bennett (R-UT), and Christopher Bond (R-MO). In 2007, Democrats and Republicans introduced a bi-partisan bill containing the mandate.

In 2008, then presidential candidate Barack Obama was opposed to the individual mandate. He stated the following in a Feb. 28, 2008 interview on the Ellen DeGeneres show about his divergent views with Hillary Clinton:

"Both of us want to provide health care to all Americans. There’s a slight difference, and her plan is a good one. But, she mandates that everybody buy health care. She’d have the government force every individual to buy insurance and I don’t have such a mandate because I don’t think the problem is that people don’t want health insurance, it’s that they can’t afford it. So, I focus more on lowering costs. This is a modest difference. But, it’s one that she’s tried to elevate, arguing that because I don’t force people to buy health care that I’m not insuring everybody. Well, if things were that easy, I could mandate everybody to buy a house, and that would solve the problem of homelessness. It doesn’t."

By 2010, the Patient Protection and Affordable Care Act (PPACA), sometimes referred to as "Obamacare,” had passed in both the House and the Senate with no Republican votes. On Mar. 23, 2010 President Obama signed the act containing an individual mandate into law. On Jan. 5, 2011, Republicans in the US House of Representatives introduced The Repealing the Job-Killing Health Care Law Act (HR 2) to repeal the PPACA. One of their main arguments for repeal was that the health insurance mandate was unconstitutional.

The two charts below provide a brief timeline of the legislative history of bills containing an individual health insurance mandate as well as the policy origins of the individual health insurance mandate.

I. Federal Health Care Bills Containing an Individual Health Insurance Mandate, 1993-2009
Date Bill Sponsor(s) CRS* Description of Individual Mandate
1. Nov. 20, 1993
(date introduced)
Consumer Choice Health Security Act (SB 1743) (624 KB) Sponsored by Senator Don Nickles (R-OK) & 24 Republican cosponsors "Subtitle C: Employer Provisions - Requires employers to: (1) withhold health insurance premiums from employee wages and remit such premiums to the employee's chosen insurer; and (2) notify employees of their right to claim an advance refundable tax credit for such premiums."
2. Nov. 23, 1993
(date introduced)
Health Equity and Access Reform Today Act (SB 1770) (1.6 MB) Sponsored by Senator John H. Chafee (R-RI) & 20 cosponsors (2-D, 18-R) "Subtitle F: Universal Coverage - Requires each citizen or lawful permanent resident to be covered under a qualified health plan or equivalent health care program by January 1, 2005. Provides an exception for any individual who is opposed for religious reasons to health plan coverage, including those who rely on healing using spiritual means through prayer alone."
3. Jan. 18, 2007
(date introduced)
Healthy Americans Act (SB 334) (427 KB) Sponsored by Senator Ron Wyden (D-OR) & 17 cosponsors (7-D, 1-I, 9-R) "Healthy Americans Act - Requires each adult individual to have the opportunity to purchase a Healthy Americans Private Insurance Plan (HAPI). Makes individuals who are not enrolled in another specified health plan and who are not opposed to coverage for religious reasons responsible for enrolling themselves and their dependent children in a HAPI plan offered through their state of residence. Sets forth penalties for failure to enroll."
4. Feb. 5, 2009
(date introduced)
Healthy Americans Act (SB 391) (394 KB) Sponsored by Senator Ron Wyden (D-OR) & 14 cosponsors (8-D, 1-I, 5-R) "Healthy Americans Act - Requires each adult individual to have the opportunity to purchase a Healthy Americans Private Insurance Plan (HAPI), which is: (1) a plan offered by a state; or (2) an employer-sponsored health coverage plan. Makes individuals who are not enrolled in another specified health plan and who are not opposed to coverage for religious reasons responsible for enrolling themselves and their dependent children in a HAPI plan offered through their state of residence. Sets forth penalties for failure to enroll."
5. Dec. 24, 2009
(date passed)
Patient Protection and Affordable Care Act (HR 3590) (2.2 MB) No sponsors. Bill re-written by Senate Democrats. No Republican Senator voted for the bill. Read more. "Subtitle F: Shared Responsibility for Health Care - Part I: Individual Responsibility - (Sec. 1501, as modified by section 10106) Requires individuals to maintain minimal essential health care coverage beginning in 2014. Imposes a penalty for failure to maintain such coverage beginning in 2014, except for certain low-income individuals who cannot afford coverage, members of Indian tribes, and individuals who suffer hardship. Exempts from the coverage requirement individuals who object to health care coverage on religious grounds, individuals not lawfully present in the United States, and individuals who are incarcerated."

* CRS is the acronym for the Congressional Research Service.

II. Policy Origins of Individual Mandate, 1989-1994
Date & Publisher Study & Author Description of Health Insurance Mandate from Publication
1. Oct. 2, 1989

Heritage Foundation
Assuring Affordable Health Care for All Americans (1.6 MB) , by Stuart M. Butler * "[N]either 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...

Society does feel a moral obligation to insure that its citizens do not suffer from the unavailability of health care. But on the other hand, each household has the obligation, to the extent it is able, to avoid placing demands on society by protecting itself...

A mandate on households certainly would force those with adequate means to obtain insurance protection."

2. Spring 1991

Health Affairs
A Plan For Responsible National Health Insurance, by Mark V. Pauly, Patricia Damon, Paul Feldstein and John Hoff "(3) All citizens should be required to obtain a basic level of health insurance. Not having health insurance imposes a risk of delaying medical care; it also may impose costs on others, because we as a society provide care to the uninsured. The risk of shifting costs to others has led many states to mandate that all drivers have liability insurance. The same logic applies to health insurance...

The obligation to obtain basic health insurance should be placed on the individual, not on the employer...

In our scheme, every person would be required to obtain basic coverage, through either an individual or a family insurance plan."

3. Mar. 5, 1992

Heritage Foundation
The Heritage Consumer Choice Health Plan (10 MB) , by Stuart M. Butler "Step #2: Require all households to purchase at least a basic package of insurance, unless they are covered by Medicaid, Medicare, or other government health programs.

All Heads of households would be required by law to obtain at least a basic health plan specified by Congress...

The private insurance market would be reformed to make a standard basic package available to all at an acceptable price...

Employers would be required to make a payroll deduction each pay period, at the direction of the employee, and send the amount to the plan of the employee's choice."

4. Jan. 1994

Health Affairs
Personal Freedom, Responsibility, and Mandates, by Robert E. Moffitt "Absent a specific mandate for at least catastrophic health insurance coverage, some persons, even with the availability of tax credits to offset their costs, will deliberately take advantage of their fellow citizens by not protecting themselves or their families, with the full knowledge that if they do incur a catastrophic illness that financially devastates them, we will, after all is said and done, take care of them and pay all of the bills. They will be correct in this assessment...

An individual mandate for insurance, then, is not simply to assure other people protection from the ravages of a serious illness, however socially desirable that may be; it is also to protect ourselves. Such selfprotection is justified within the context of individual freedom; the precedent for this view can be traced to none other than John Stuart Mill."

5. June 13, 1994

Cato Institute
Cato Institute Policy Analysis No. 210: Nickles-Sterns Is Not the Market Choice for Health Care Reform (98 KB) , by Tom Miller "The Consumer Choice Health Security Act, of which Sen. Don Nickles (R-Okla.) and Rep. Cliff Stearns (R-Fla.) are primary sponsors, is one of the leading proposals for health care reform. Unfortunately, it sets contradictory objectives: universal coverage and increased consumer choice, individual responsibility, and competition in health insurance markets...

The most troubling aspect of the Nickles-Stearns legislation, as introduced on November 20, is the mandate that it imposes on all Americans to purchase a standard package of health insurance benefits. By endorsing the concept of compulsory universal insurance coverage, Nickles-Stearns undermines the traditional principles of personal liberty and individual responsibility that provide essential bulwarks against allintrusive governmental control of health care."


* About his Oct. 2, 1989 Heritage Foundation report, considered to be the origin of the health insurance mandate, Stuart Butler wrote in his Feb. 3, 2012 USA Today article: "My view [advocating for a health insurance mandate] was shared at the time by many conservative experts, including American Enterprise Institute (AEI) scholars, as well as most non-conservative analysts… My idea was hardly new. Heritage did not invent the individual mandate... Changing one's mind about the best policy to pursue — but not one's principles — is part of being a researcher at a major think tank such as Heritage or the Brooking Institution… I've altered my views on many things. The individual mandate in health care is one of them.”

Sources:

Bradley Latino, "The Individual Mandate, a Brief History - Part I, Conservative Origins," www.healthreformwatch.com, Feb. 14, 2011

Congressional Budget Office (CBO), "A Qualitative Analysis of the Heritage Foundation and Pauly Group Proposals to Restructure the Health Insurance System," www.cbo.gov, Apr. 1994

Consumer Choice Health Security Act (SB 1743), US Government Printing Office (accessed Feb. 23, 2011)

Edmund F. Haislmaier, "What's Wrong with America's Health Insurance Market," Heritage Foundation, Aug. 14, 1992

Ezra Klein, "An Interview with Mark Pauly, Father of the Individual Mandate," Washington Post, Feb. 1, 2011

Ezra Klein, "The Justice Will See You Now: The Fate of Obama's Health-Care Law May Rest with One Man," Newsweek, Feb. 6, 2011

Healthy Americans Act (SB 334), US Government Printing Office (accessed Feb. 23, 2011)

Healthy Americans Act (SB 391), US Government Printing Office (accessed Feb. 23, 2011)

Health Equity and Access Reform Today Act (SB 1770), US Government Printing Office (accessed Feb. 23, 2011)

Iain Murry, "A Long History of Opposition to the Individual Mandate," www.nationalreview.com, Feb. 2, 2011

Julie Rower, "Republicans Spurn Once-Favored Health Mandate," www.npr.org, Feb. 14, 2011

Mark V. Pauly, Patricia Damon, Paul Feldstein and John Hoff, "A Plan For Responsible National Health Insurance," Health Affairs, 1991

Patient Protection and Affordable Care Act (HR 3590), US Government Printing Office (accessed Feb. 23, 2011)

Robert E. Moffitt, "Personal Freedom, Responsibility, and Mandates," Health Affairs, 1994

Ronald Bailey, "Mandatory Health Insurance Now!," www.reason.com, Nov. 2004

Stuart M. Butler, PhD, "Assuring Affordable Health Care for All Americans," Heritage Foundation, 1989

Stuart M. Butler, PhD, "The Heritage Consumer Choice Health Plan," Heritage Foundation, Mar. 5, 1992

Tom Miller, "Cato Institute Policy Analysis No. 210: Nickles-Sterns Is Not the Market Choice for Health Care Reform," www.cato.org, June. 13, 1994