The roadmap for what was then the signature Republican approach to health-care reform was provided by the once quintessentially Reaganaut think tank, the Heritage Foundation, which now denounces “the cancer of Obamacare.”  The offending document was written in 1989, at the dawn of the first Bush presidency, and its rationale for the individual mandate was as follows:

“There is an implicit contract between households in society, based on the notion that health insurance is not like other forms of insurance protection. If a young man wrecks his Porsche and does not have the foresight to obtain insurance, we may commiserate but society feels no obligation to repair his car. Healthcare is different. If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance. If we find that he has spent his money on other things rather than insurance, we may be angry but we will not deny him services – even if that means more prudent citizens end up paying the tab … A mandate on individuals recognizes this implicit contract.”

This is, of course, almost precisely the argument made by both the Obama administration and Governor Romney when he was preparing his signature legislative accomplishment in Massachusetts. Namely, that we have a hole in the social contract, where a lack of individual responsibility causes great financial costs for society as a whole in the realm of health care, which everyone will need at some point in their lives. The solution, reiterated several times by Heritage in policy papers leading up to the fight over Hillarycare, was to put an end to fiscally irresponsible freeloaders by advancing the principle of individual responsibility. By comparison, the Clinton health plan’s imposition of a requirement for employers to provide health insurance purchased through HMOs seemed positively socialistic.

In another time, President Obama’s adoption of a Republican policy to pass health-care reform could have been characterized as classic Clintonian triangulation, an extension of the dynamic that enabled a Southern Democrat like Lyndon Johnson to pass civil-rights legislation or Nixon to go to China.

Obama has done no harm to civil liberties or the Bill of Rights (except in the category mentioned above). He’s made no move of any sort to curtail the Second Amendment. Wayne LaPierre and his people at the NRA are always warning that it’s only a matter of time; a second Obama term will “break the back of the Second Amendment,” La Pierre said not long ago. That’s how he keeps the checks coming in. Of course there is no evidence for this claim. Just the murky (not to say insane) idea that a black liberal loves criminals and wants law-abiding white people not to be able to defend themselves.

As I read through a few web pages and blogs detailing alleged Obama-driven assaults on freedom, it becomes clear that many of these people don’t really have the faintest idea of what freedom in a Democratic society even means. Here, for example, is a Republican congressional hopeful in Missouri, who thinks Obama, along with his own opponent Russ Carnahan, want to take away “the ultimate freedom, to find your salvation, to get your salvation, and to find Christ for me and you, and I think that’s one of the things we have to be very, very aware of that the Obama administration and Congressman Carnahan are doing to us.”

This is just gobbledygook. What this man doesn’t like is Obama’s posture toward the state and religion. But there is no freedom issue here. Neither is there a freedom issue with regard to the Catholic Church and the recent controversy over contraception. First of all, no church has to change a single thing about the way it operates. And Catholic hospitals will not, under the new rule, have to provide contraceptive coverage—they will just be required, if they refuse to provide such coverage, to tell enrollees how they can acquire it through other means. In fact, now that I think about it, the only people who can make any claims that their freedoms are being impinged by the Obama administration are the non-Catholic women hired by Catholic hospitals who might now have trouble getting free contraceptive coverage. Them, plus the women inquiring about abortion in the states where they will now be made to listen to fetal heartbeats and so on, laws that very clearly are attempts to coerce women into not availing themselves of an existing legal right. But that isn’t being done by Obama.

The silliness of the freedom argument against Obama really comes down to this: The ACA was a law, made within our political processes, according to the rules and norms of same. Obama isn’t the king. He didn’t decree this law. Congress negotiated it and passed it. If people don’t want such laws, they need to elect Congresspeople that won’t make them. This, incidentally, is the answer to an oft-bruited rhetorical question, “What’s to prevent the government from making a law requiring that everyone eat broccoli?” One answer is: nothing, at least in theory. If a future Congress wants to make such a law, it can do so and see what happens in the courts. Which means that the real answer is—politics. If you don’t want a law mandating the eating of broccoli, work to elect people to Congress who won’t pass such laws. The folks on the pro-broccoli side will work to do the opposite, and the side that does a better job will win. That’s the democratic process. Majority rule. “Freedom” has nothing to do with it.

And it is not just individuals like Carlos who face this ugly market: anyone who might lose their job, or have an employer that stops offering insurance, can find themselves facing this nightmare. I show this happening to Anthony, who has good employer-provided insurance but loses that coverage and has to face the awful non-group insurance market as a result. This is a real threat to many with employer-provided insurance: the share of employees covered by employer-sponsored insurance has declined by more than 10% over the past decade.

How can we fix this problem? A number of well-meaning states tried to do so in the mid-1990s. They passed regulations that outlawed discriminatory practices by insurers, like pre-existing conditions exclusions and charging sicker individuals higher prices. The result was a disaster. Insurers were afraid that if they had to charge everyone the same price, but that individuals could wait until they were sick to buy insurance, that this would become a money-losing business. So some insurers exited the markets, while the ones that stayed charged very high prices to offset this “adverse selection.” Non-group insurance markets in these states were not saved, but rather largely destroyed. For example, in my home state of Massachusetts, by 2006 a non-group policy for a single individual cost $8,000 per year, twice the cost of an employer policy for an individual.

Into this chasm stepped the hero of our story, Governor Mitt Romney, and his plan for health-care reform in Massachusetts. He realized that the solution to this problem was to ensure broad participation insurance markets by both the healthy and the sick. So he imposed an individual mandate, a requirement on Massachusetts residents to purchase insurance coverage. But he also realized that it would be both inhumane and impolitic to mandate that individuals purchase insurance they could not afford. For this reason he also provided for subsidies for individuals living below three times the federal poverty line to make insurance affordable. This “three-legged stool”—banning discrimination in insurance markets, mandating that individuals purchase insurance, and providing low-income subsidies for insurance purchase—became the basis for both our reform in Massachusetts and for the Affordable Care Act (ACA).

Therefore, these economists argue, deciding to be uninsured is not “inactivity,” but rather a commercial decision to self-insure the expected costs of unavoidable commercial activity. In other words—you’re going to have to see the doctor eventually, so who pays? Because the uninsured often cannot afford the treatments they need, health-care providers will incur the resulting costs, either out of decency or legal duty, and then pass those costs on to taxpayers and the insured. Indeed, nearly two thirds of the costs of treating the uninsured are paid by others, with the total incurred by providers estimated by Congress to be $43 billion in 2008.

In contrast, if we decide we don’t want to buy broccoli or a GM car next year, we are in full control of that decision. So, we can be inactive in ordinary markets in a way we cannot be for health care, where illness thrusts activity upon us.

So what about the economists who oppose the mandate?

They argue that the amount of cost-shifting caused by the uninsured is smaller than Congress’s $43 billion figure. Many of their objections are economically powerful, but legally their effort falls flat because even they concede that the shifted costs are at least $12.8 billion, and the court has upheld federal laws based on far more trivial effects on interstate commerce. Moreover, in the end, the numbers don’t matter: No one disputes that Congress may regulate commercial activity regardless of whether it imposes costs on others. So even if uninsured people cost us nothing, they are still “active” in the health-care markets, and the opposing brief does not really deny this (even though it quibbles about the precise extent to which that activity is unavoidable).