![]() ![]() Public support for the Clinton plan plummeted, and it attracted only tepid backing from congressional Democrats while drawing intense Republican opposition (Hacker 1996 Johnson and Broder 1997 Skocpol 1996). It alienated already insured, middle-class Americans who worried that reform would worsen their access to medical care and health system stakeholders who feared that the plan would hurt them financially. Democrats' autopsy on the Clinton administration's disastrous 1993β94 health reform campaign concluded that it died in part due to an excessively ambitious plan. The ACA reflected a political theory of health reform that illuminates much about its postenactment achievements and tribulations. I focus here on the challenges associated with the ACA's efforts to increase access to health insurance and on the political dynamics that have shaped its implementation. Because the law aims to do many things-expand access to health coverage, control health care spending, transform medical care payment and delivery, and more-it is impossible to cover all of those policy domains in this space. How has the Obama administration fared in meeting these challenges? What does the ACA's performance to date tell us about the promise and limits of health care reform? And how might the ACA's trajectory change in coming years? David Mechanic ( 1994: 44) noted long ago that βit is far too easy to construct a utopian health care system that has no possibility of implementation.β The ACA offers a window into the real world of implementation. ![]() Moreover, implementation also has (or in some cases, should have) entailed efforts to build a political constituency for the ACA, reassure a confused and anxious public about Obamacare's impact, and persuade reluctant and sometimes hostile state policy makers to participate in the reform project. The Obama administration and its allies have faced a formidable array of implementation challenges: establishing myriad new institutions, promulgating and enforcing numerous regulations, getting a complicated insurance enrollment system up and running across the country, educating tens of millions of potential enrollees about the law's benefits, and initiating a plethora of experiments in payment and delivery system reform. Yet if the ACA's enactment proved that substantial health reform was indeed possible to legislate in the United States, the past six years have demonstrated how difficult it is to implement such reform. They surmounted multiple hurdles that easily could have tripped up reformers once again, the most treacherous being the loss of a filibuster-proof Senate supermajority following Ted Kennedy's death and Scott Brown's subsequent election (Brown 2011 Cohn 2010 Jacobs and Skocpol 2010 McDonough 2011). The Obama administration and congressional Democrats beat the odds, reversing a long record of disappointment and failure in health reform. Passage of the 2010 Patient Protection and Affordable Care Act (ACA) was a remarkable political feat. Affordable Care Act, Obamacare, health reform implementation ![]()
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