Lawrence R. Jacobs - Health Care Reform and American Politics: What Everyone Needs to Know

PREFACE AND ACKNOWLEDGMENTS

On March 23, 2010, President Barack Obama signed into law a landmark in U.S. social legislation, the Patient Protection and Affordable Care Act. In the two weeks before the critical vote on the first day of spring, and especially in the hours before, the two authors of this book were e-mailing back and forth furiously. Would the President and House Speaker Nancy Pelosi manage to cobble together enough votes from House Democrats to pass comprehensive health reform? Would quarrels over abortion derail the deal at the last minute? Which provisionsspelling out who would benefit, and who would paywould remain in the bill at the end?

Our interest was intense not just because the outcome was uncertain until almost the last minute, but also because both of us, Larry Jacobs and Theda Skocpol, have been fascinated by the politics of health care reform for many years. We have written about past battlesfor Medicare, for Clintons failed Health Security reformand we have thought about what successes and failures in social-policy battles mean for American politics. Even before Obamas White House signaled in early 2009 that it would proceed with a gargantuan effort to get Congress to pass comprehensive health reform amidst partisan polarization, the Great Recession, and intense special interest lobbying, the two of us had geared up to look at health care issues in the Obama presidency. After all, this was a Democratic President who came to office, along with large Democratic Congressional majorities, at a time when the U.S. health care system was clearly brokenfacing skyrocketing costs and receding coverage of health care for middle-class and lower-income families. Obama and other Democrats had promised to act on much-needed reforms. Would they try to keep their promise, even after the economic crises intensified and Republicans signaled total opposition? Would they succeed, or fall short as so many would-be reformers before them had done? It was bound to be a fascinating political story that would tell us a lot about what is possible, and not, in U.S. politics in the early twenty-first century.

Many others have helped us get it done. David McBride at Oxford University Press saw the potential and supported our effort to move quickly, as did Alexandra Dauler. Invaluable and highly skilled research assistance was provided by Melanie Burns and Charles Gregory at the University of Minnesota, and by Vanessa Williamson at Harvard University (who not only worked on several chapters but also prepared the time line and glossary for this book). Larry Jacobs appreciates support from the University of Minnesota, one of the countrys original land-grant public universities, and from J. Brian Atwood, Dean of the Hubert H. Humphrey School of Public Affairs. We are grateful to the Russell Sage Foundation and its President Eric Wanner for its support of a scholarly working group on Obamas Agenda and the Dynamics of U.S. Politics. The two of us are coordinating this working group, and our research on health reform is, in part, supported by the Foundations grant. We benefited from discussions with other members of the group, each of whom is tracking a policy area of his or her own. Finally, we thank our spouses, Julie Schumacher and Bill Skocpol. Bill, as he always does with Thedas books, read through the final manuscript and made suggestions to improve clarity. Both Julie and Bill put up with their partner spending almost all the time for weeks on the challenging and fascinating task of finishing this book.

Lawrence Jacobs, St. Paul, Minnesota

Theda Skocpol, Cambridge, Massachusetts

INTRODUCTION: A TURNING POINT FOR U.S. HEALTH CARE AND POLITICS

On Tuesday, March 23, 2010, several hundred people crowded into the East Room of the White House to witness President Barack Obama sign into law the Patient Protection and Affordable Care Act. The mood was exultant, and the President was interrupted repeatedly with cheers, applause and standing ovations from more than 200 House and Senate members joined by Victoria Reggae Kennedy, widow of the late Massachusetts Senator and life-long health-reform crusader Ted Kennedy, as well as by regular citizens who had experienced first hand the travails of the nations patchwork system of health care coverage.1 Standing close, and wearing an electric blue tie just like the Presidents, was eleven-year-old Marcelas Owens of Seattle, who became an advocate for health reform after his mother died without insurance; also watching was Connie Anderson, whose sister is Natoma Canfield, the Ohio cancer patient whose struggles to pay for rising health premiums became a case in point for Mr. Obama.2

In the Presidents words on that Tuesday in the East Room, the bill Im signing will set in motion reforms that generations of Americans have fought for and marched for and hungered to see, enshrining the core principle that everybody should have some basic security when it comes to their health care. Over the course of the past century, modern health care has become increasingly effective at saving and improving lives and also steadily more expensive for individuals, businesses, and governments. Because people value health and life so much, they do all they can to pay the price for care, and can even go bankrupt in the process.3 The existing U.S. health-care financing system relies on partial government programs and patchwork private-market arrangements to protect many citizens, but far from all of them.