Flashpoint in Health-Care Reform

Fighting for Our Health:
The Epic Battle to Make Health Care a Right in the United States
by Richard Kirsch
Rockefeller Institute Press, 2012, 416 pp.

Remedy and Reaction:
The Peculiar American Struggle Over Health Care Reform
by Paul Starr
Yale University Press, 2011, 336 pp.

Health care is an explosive flashpoint in U.S. politics this year more than ever. By 2013, Americans will either be headed, however slowly and fitfully, toward virtually universal access to decent health care or most of us will be struggling to use dwindling public vouchers to purchase ever more expensive private insurance. These alternate futures reflect what will happen if there is a Republican takeover of the presidency and Congress in January 2013 compared to what is likely if Barack Obama secures re-election in November 2012 or if Democrats have control of at least one chamber of Congress.

Four years ago, proposals to expand health insurance coverage were a hot topic among candidates Obama, Hillary Rodham Clinton, John Edwards, and John McCain. Citizen groups and health-care stakeholders alike realized that 2009 might bring another attempt at legislating “comprehensive health reform”—to expand coverage to tens of millions of uninsured and get a grip on rising health-care costs. That is just what happened, although the legislative slog was long and hard. In March of his second year in office, Obama signed into law the Patient Protection and Affordable Care Act of 2010.

This reform promises massive federal subsidies to make decent health insurance coverage available at a reasonable price to lower- and lower-middle-income Americans. States will set up regulated “exchanges” through which citizens and businesses can compare and purchase health coverage. States can choose to feature public health plans, even to institute single-payer coverage, as Vermont is doing. Where private insurers are allowed to offer coverage and use subsidies on the exchanges, they will have to make profits by offering better coverage at lower cost, not by avoiding or dumping patients who suffer chronic conditions or become ill.

Major social policy breakthroughs like Affordable Care always remain contentious for years after a president signs the bill into law. Social Security was under partisan attack for years and took two decades to become securely vested; the implementation of Medicare amid cries of “socialism” led to sharply rising costs and launched battles over cost controls that have never gone away. Since its enactment, Affordable Care is actually being implemented more steadily than media coverage would lead us to believe. Many Republican governors whose attorneys general are arguing that Affordable Care is unconstitutional have nevertheless accepted federal subsidies to expand coverage and plan for the new health-care exchanges.

Across the country, insurance companies, hospitals, ...