When health insurance developed in the United States in the 1930s, it covered hospital and later major medical bills, not preventive services. Insurance also had nothing to do with public health. And when Medicare was enacted in 1965, it too made no provision for preventive and public-health services.
The Affordable Care Act is different. Culminating a long shift in thinking, it incorporates preventive care into health insurance and seeks to promote public health through provisions aimed at reducing obesity and smoking and encouraging participation in wellness programs.
Carrying out health-care reform presents challenges far beyond those of ordinary legislation or even such landmarks as Social Security and Medicare. After a law establishes a new program, the next steps are usually a bureaucratic process of policy implementation. But the legislation passed by Congress last March, the Patient Protection and Affordable Care Act, will need to run a gauntlet of treacherous hurdles and be politically implemented.
President-elect Bush meets with Vice President Al Gore, Dec. 19, 2000. (AP Photo/J. Scott Applewhite)
It's months before the November elections, and Republicans have practically broken out the champagne to celebrate their coming victories, while many liberals are chalking up prospective losses to the failure of the president and congressional Democrats to be ambitious enough. Excuse me if I don't join in the "precriminations." The elections may turn out badly, but the achievements of the administration's first year and a half have been more than respectable, and I doubt that more progressive policies could have borne fruit quickly enough to alter the results in November. Nor do I believe that Democrats have overreached, only to suffer the predictable reaction from a "center right" society.
Something feels wrong about the state of American politics. With millions unemployed and home foreclosures at record levels, the country is still suffering acutely from the recession's effects, yet the Tea Party is the only movement that can put thousands of people into the streets. How is it that so soon after activists helped Barack Obama win the presidency, the left is quiet while feet march and fires burn on the right?
President Barack Obama at Arcadia University in Glenside, Pa., Monday, March 8, 2010. (AP Photo/Charles Dharapak)
If the House of Representatives passes the Senate health-care reform bill with the changes recommended by President Barack Obama, and the Senate then passes those final changes through reconciliation, no one will be more pleased than I (see "Underrating Reform" in the Prospect's March issue).
But suppose that after the White House and congressional leadership press their case, twist arms, and count heads, they are still short of the votes they need. Should they just give up on the legislation, or can they make any additional concession to attract votes while preserving the aims of reform?