Much of David Frum’s work over the past several years has been dedicated to advancing the idea that small government conservatives are pushing Republicans in an extreme direction, leading them to embrace wrongheaded policies that, in the end, will cost them politically. In the latest attempt to advance this theme, Frum argues that had Mitt Romney not been forced to back away from it, Romneycare would have been an ideal way for him to counter President Obama’s charges that his wealth has made him oblivious to the struggles of working class Americans. But in the process of making his case, Frum unfairly caricatures conservative critics of Romneycare and misrepresents the policies enacted by the Massachusetts health care law.

In describing how Romney backed away from his health care law during the Republican primaries, Frum writes that, “Romney retreated under attack. Not his finest hour, but sometimes discretion is the better part of valor. Attempting to reason with enraged people may only enrage them more.” It’s a cheap shot for Frum to describe conservative critics of Romneycare during the primary as if we were “enraged” children without engaging the actual criticisms of the law. Some of us simply don’t believe that the way to fix our health care system is for the government — whether at the federal or state level — to mandate, regulate and subsidize the purchase of health insurance.

Frum then argues that Obamacare is not a major issue of the campaign.  Yet even after the Supreme Court ruling upholding the constitutionality of the law, polls show the public is opposed to Obamacare by upwards of a double-digit margin. It’s clearly an issue that could theoretically be used by Republicans, just as it was in 2010, when it played a central role in the GOP’s takeover of the House. But the reason why health care isn’t much of an issue is precisely because Romney is the nominee and can’t credibly argue against Obamacare given his own record.

Frum insists:

It seems silly to let the party base drive a national campaign into places that are bad politics, bad policy, and untrue to the party nominee’s own biography. Instead of allowing opposition to Obamacare to entrap Romney into repudiating his own healthcare record altogether, he should explain to a national audience what the Republican primary electorate did not want to hear: that Obamacare is flawed because it pays for itself with an especially destructive set of tax increases, because it expands Medicaid too much rather than relying on private insurance, and because it does not include enough cost-saving.

Though I agree with these criticisms of Obamacare, all of them would be more difficult for Romney to make were he to embrace the Massachusetts health care law as a central part of his candidacy. Romneycare didn’t have to rely on the same tax hikes as Obamacare, because about half of the law was funded by the federal government through the Medicaid program. Also, the passage of the Massachusetts law led to tax increases after Romney left office due to budget shortfalls it helped exacerbate. Romneycare, like Obamacare, expanded Medicaid and did not contain health care costs. In fact, some policy analysts sympathetic to the law defend the cost increases by saying the law wasn’t meant to contain costs in the first place. As the Kaiser Foundation put it in a recent analysis (PDF): “The state continues to struggle with rising health care costs. State health reform in 2006 purposefully focused on expanding coverage to residents while leaving the thornier task of cost containment for future years. As a result, affordability continues to be an issue.”

Frum would like for us to believe that extremists have forced Romney to take positions that have hindered his electability. But the reality is that no Republican candidate can win a national campaign without the enthusiastic support of conservatives, and they have every right to try and pressure Romney into moving closer to their policy positions in exchange for their backing. Though the conventional wisdom is that appeasing conservatives alienates moderates during the general election, that wasn’t the case with the GOP’s landslide victories in 1980, 1994 and 2010. The awkward situation that Romney finds himself in when it comes to health care policy isn’t an argument for Republicans to ignore conservatives during the general election. It’s an argument against Republican politicians ever embracing big government policies at any level of office if they intend to run as small government conservatives down the road.