Doc Obama's Long Road
When Obama managed to get health care reform through Congress, many were astonished. For decades similar attempts had come to naught , but when this reform also seemed doomed, the President put all his weight behind the bill and mobilized all Democrats to get it approved by Congress. Now we realize the battle is not over and that legislation initiated by Obama is still in danger of being undermined with the real risk of a stalemate.
The reform promised to tackle two structural problems: the lack of health coverage for 40 million Americans and uncontrolled growth in health spending. The existence of a significant portion of the population without any form of coverage is felt as a major fault by American society, as well as a source of inefficiency. Uninsured citizens are not appropriately managed, because they receive little basic medical assistance and prevention; they crowd emergency rooms, because that's the only way they're entitled to receive medical care. According to estimates, the lack of universal coverage causes 40,000 premature deaths every year. Obama's health reform introduces mechanisms to strongly reduce, albeit not bring down to zero, the number of uninsured people: it foresees public coverage for families with incomes under 133% of the poverty line, the introduction of tax benefits, and mandatory insurance coverage.
On the cost front, the interventions are about promoting managed care systems, strengthening the assessment of medical effectiveness, development of disease prevention, and improved efficiency in the provision of health services. These two major objectives are pursued by a complex piece of legislation that requires a major effort in implementation. The final outcome will depend on the still ongoing dispute between actual implementation, political debate, and the Constitution.
The first hurdle is whether the reform is constitutional, particularly in the part that makes health insurance mandatory. Opponents argue that such an obligation is a violation of individual freedom and disregards the powers attributed to States in the Constitution. The Supreme Court will emit its verdict in 2012. Only then we will know whether this important pillar of the reform will be safeguarded or not.
The second obstacle is political conflict. Obama got the full support of Democratic Representatives and Senators behind the law, but also got fierce opposition from the GOP, which has sworn to boycott and alter the law. As long as Obama is president, his veto power makes sure that the law won't be changed. But if the Republicans should get to the presidency, they would probably introduce legislation to undermine health care reform. As such, the debate is strongly polarized: on one side 40% of the people and the Democratic Party defending the law on grounds of social justice and economic rationality, on the other the GOP and another 40% of citizens who fear that health insurance costs will go up. It's a clash of opposing worldviews: the free-market vs regulation, personal freedoms vs social justice.
The third hurdle concerns implementation. The reform calls for a series of measures to be implemented by 2018. It thus needs regulations, establishment of new agencies and the cooperation of state governments. And this is where the battle gets ugly, with bureaucratic boycotts on specific political and administrative passages of the law.
Thus most of US health care reform is still on paper. Its future will depend on the Supreme Court, on whether Obama will maintain power and the ability of policymakers to navigate the tortuous path to make its major provisions operational.