Health Care Reform: The Politics of Fear

The adoption of the Patient Protection and Affordable Care Act (ACA) in 2010 was an historic achievement in U.S. health policy. Reformers had tried, and failed, to adopt comprehensive health care reform since the Progressive Era. Opponents of the ACA attempted to frame the reform as a threat to American values and a threat to the quality of the American health care system. In doing so, they adopted themes and language that have appeared during every previous attempt at reform. This paper will document the similarities and differences between the debate over the ACA and previous health reform debates since 1910. These include the Progressive Era push for “compulsory” health insurance at the federal and state level, the flirtation with national health insurance (NHI) during the administration of Franklin Roosevelt, President Truman’s efforts to adopt NHI, the “partial” success of Medicare and Medicaid, as well as subsequent efforts to adopt reform by President’s Nixon, Carter and Clinton. Although the political rhetoric about the ACA was strikingly similar to these previous debates, the outcome was different. The paper will review the factors that help to explain why reform was finally adopted, but why its future remains fragile and uncertain. President Obama enjoyed political circumstances that made success more likely than previous attempts at reform, but he also adopted a strategy that helped to avoid some of the barriers previous presidents encountered. Unfortunately, his decision not to include more aggressive cost control measures in the ACA may undermine the extent to which it addresses the problem of medical insecurity.