The Supreme Court will rule next year on the constitutionality of the healthcare reform passed in 2010. But constitutionality notwithstanding, Republican opposition to the new law has been vigorous and consistent. In recent GOP presidential debates the candidates have been unanimous in condemning it, in particular objecting to the requirement that almost all Americans obtain health insurance or pay a penalty.

On the surface, Republican and conservative opposition to the new requirement seems perfectly logical. There is a long history of conservative preference for limited government and individual responsibility.

But scratching the surface of those principles reveals a murkier picture. There is a compelling conservative case for the requirements imposed under healthcare reform. Indeed, during the 1980s and early 1990s, many moderate GOP policymakers championed an individual mandate. For example, in 1993, Sen. John Chafee (R-R.I.) had 16 Republican co-sponsors, among them Kansas Sen. Bob Dole, for a reform proposal that included the mandate. President Clinton and other Democrats favored a requirement that employers provide insurance, and roundly rejected the notion that the requirement be shifted from employers to individuals.

The conservative case for an insurance requirement starts with the assumption that almost any responsible adult, and certainly one with a family, is going to get health insurance, at least so long as he can afford it. He may get it through an employer or purchase it himself. Unless one is extremely wealthy, the risks of not having insurance are simply too great. Thus, to the vast majority of responsible adults, the requirement to have insurance is no requirement at all — they already buy it. The reform simply imposes a penalty if they don’t do what they would do anyway. Some may object in principle, but the actual effect on those now buying insurance is near zero.


We can, of course, conceive of several groups that might be required to do something they are not already doing. There are those who because of illness or risk factors might be charged exorbitant insurance premiums they cannot afford. There are other individuals who, even if healthy, cannot afford insurance. But the reform law addresses the needs of these groups through reform of the insurance marketplace, expansion of the Medicaid program, subsidies for the purchase of insurance and, in some cases, exemption from the requirement to have insurance. As a result, most of these individuals will be among the biggest winners in the new system. They will either gain access to affordable insurance or face no burden or penalty for not doing so.

In fact, the only individuals who may actually be forced to do something they would not do voluntarily are those who can afford insurance but choose not to buy it. It is these individuals and families whose supposed rights to not have insurance are being defended by critics of the new law. Yet these are precisely the individuals with whom strong advocates of individual responsibility should be most displeased. These people are not just putting themselves and their families at risk by not buying insurance; they are running the risk that when they cannot pay their medical bills, someone else will have to pay those bills for them.

Here the principles of limited government and individual responsibility are at odds. What is more disturbing to conservatives— that government would impose a financial requirement on irresponsible individuals , or that government, in effect, would allow their irresponsibility to impose financial burdens on those behaving responsibly?

CNN’s Wolf Blitzer raised this issue while moderating a GOP presidential debate in September. What should happen, he asked, when someone has no insurance and needs care they cannot afford? None of the candidates had much of an answer. No one suggested the individual be denied care and possibly be left to die. Yet any other imaginable answer — hospitals and physicians should provide free services, the safety net should absorb the cost, charities or government should pay for it — entails shifting costs from someone who didn’t buy insurance to someone else. If the person needing care is poor, that cost shift would seem appropriate. But what if the person unable to pay could have purchased insurance and didn’t?


Ultimately, the cost in such cases will be paid by taxpayers, or those who have bought insurance. Tax dollars support clinics, public hospitals, programs for the uninsured and charitable organizations that provide free care for the uninsured. And premiums paid by the insured rise when hospitals and doctors charge the insured more because the uninsured are unable to pay.

Where is the conservative value in this scenario?

In considering the individual mandate, conservatives need to address three questions. First, why is it so troubling that the government is requiring responsible individuals to purchase what they would purchase anyway? Second, is it fair or appropriate to make the responsible pay more in order to protect the rights of the irresponsible? Third, what should be done when the principle of limited government clashes with that of individual responsibility?

Or, put another way, is the principle of limited government so compelling that it should cause us to penalize the responsible and reward the irresponsible?


Walter Zelman, chairman of the Department of Public Health at Cal State Los Angeles, is chairman of the board of governors of LA Care, L.A. County’s Medi-Cal health plan.