Abstract
This chapter analyzes the Affordable Care Act’s (ACA) turbulent political journey and the current state of health care reform in the United States, with particular focus on developments in health politics and policy during the Obama and Trump administrations. Reforming American health care is perennially a politically treacherous task due to a combination of interest group pressures, fragmented political institutions, and a prominent anti-government strain in US political ideology. The adoption of piecemeal, incremental reforms during the twentieth century makes it difficult to enact more comprehensive solutions to the formidable problems in American health care today. Recent developments in US health politics show that it is possible to move past the inertia of the status quo—but progress is both fragile and limited. The sustained battles over the ACA’s implementation and repeal are shaped by growing ideological and political divisions between Democrats and Republicans, and partisan polarization has altered the normal political trajectory that follows the enactment of a major new social policy program like the ACA. The chapter explains why the ACA proved much more politically vulnerable than initially anticipated, but also resilient despite sustained efforts to roll it back. The chapter also considers the impact of Covid-19 and how the (dis)organization of American health care and health policy has complicated the challenge of responding to the pandemic in the United States.
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Further Reading
The involvement of presidents from Franklin Delano Roosevelt to Barack Obama in health care reform is vividly explored in David Blumenthal and James Morone’s (2009) The Heart of Power (Berkeley: University of California Press). Other excellent accounts of the history and politics of US health policy during the twentieth century include Paul Starr’s (2nd edition, 2017) The Social Transformation of American Medicine (New York: Basic Books), Theodore Marmor’s (2nd edition, 2000) The Politics of Medicare (London: Routledge), and Jacob Hacker’s (1996) The Road to Nowhere (Princeton: Princeton University Press).
There is a large and growing literature on the politics of the Affordable Care Act (ACA). John McDonough’s (2011) Inside National Health Reform (Berkeley: University of California Press) and Paul Starr’s (2011) Remedy and Reaction (2011) (New Haven: Yale University Press) explore the remarkable constellation of political forces and choices that led to the law’s enactment as well as the promise and limits of the ACA’s design. The post-enactment conflicts over the ACA at the state level and in the context of federalism are skillfully analyzed by Daniel Béland, Philip Rocco, and Alex Waddan’s (2016) Obamacare Wars and David Jones’ (2017) Exchange Politics (New York: Oxford University Press). Jamila Michener’s excellent (2018) Fragmented Democracy (Cambridge: Cambridge University Press) goes beyond the ACA to show how federalism reproduces inequalities in state Medicaid programs and how enrollment in such programs impact political participation by low-income beneficiaries.
Recent scholarship in American health politics has also examined the formidable barriers to controlling health care costs. Miriam Laugesen’s (2016) Fixing Medical Prices (Cambridge: Harvard University Press) and Eric Patashnik, Alan Gerber, and Conor Dowling’s (2017) Unhealthy Politics (Princeton: Princeton University Press) are exceptional accounts of the political forces that shape US health care spending. Beyond the scholarly literature, the Kaiser Family Foundation (https://www.kff.org/) and Commonwealth Fund (https://www.commonwealthfund.org/) are essential sources of news, data, and analysis of current issues in U.S. health care policy.
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Oberlander, J. (2022). Health Care Reform. In: Peele, G., Cain, B.E., Herbert, J., Wroe, A. (eds) Developments in American Politics 9. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-89740-6_15
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