Health Reform Without Apology
The Affordable Care Act is under relentless attack from conservatives. Yet progressives are too ambivalent about defending it.
Implementation of the ACA opens a new chapter in the politics of health policy, much as the passage of the Social Security Act in 1935 started a struggle over income security for seniors that continued for generations. As with the ACA, Social Security began as a limited program that fell far short of reformers’ preferred remedies, leaving out, for example, agricultural and domestic service workers. To win votes in Congress (especially southern Democrats), the legislation excluded about two-thirds of all African-American workers (upwards of 80 percent in parts of the South) and over half of all working women.
The story of limited beginnings followed by expansion is common. It also describes the trajectory of Medicare, whose benefits have widened considerably since its passage in 1965 and is now a potential platform for a single-payer system. The ACA fits within America’s history of pragmatic realism. If the ACA withstands today’s savage onslaught in the face of tepid support from many of its natural adherents, it will likely generate a range of options for the next round of reformers intent on further widening access and controlling costs. Tomorrow’s pragmatic problem-solvers are likely to build on the ACA’s areas of effectiveness and the new precedents it sets and to seek new solutions to its shortfalls.
Opponents of reform well understand the significance of the ACA for future health policy, which accounts for their speed and ferocity in building well-financed and potent national and state operations. This level of awareness and engagement is less evident among supporters of reform—including advocates for single-payer financing and the public option. The future of health reform—and the remedies most favored by progressives—depends on sustaining the ACA by conveying its importance in clear and compelling terms, by building inclusive coalitions, and by exploiting the new developmental trajectories that the ACA initiates.
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