Last year’s three-ring Congressional shutdown circus — for many little more than a desperate rearguard action by an isolated right-wing fringe to undo the fait accompli of Barack Obama’s health care reform — reinforced with each passing day the gaudy dysfunction of the American political system. But we miss something crucial if we construe the perseverance of Barack Obama’s 2010 Affordable Care Act (ACA) as nothing more than the overdue victory of commonsense health care reform over an irrelevant and intransigent right, or, even more, as the glorious culmination of a progressive dream for American universal health care long deferred.
For many commentators, though, this is precisely what the ACA represents. With the law’s passage in March 2010 and its survival in the face of a constitutional review by the Supreme Court, they have concluded that the battle “over universal health coverage,” as one writer for the Washington Post put it, “is basically over.” Unfortunately, the evidence does not permit such a sanguine conclusion.
Most plainly, when we consider the provisions and limitations of the law, it becomes clear that though it may help many, the ACA fails fundamentally to create what so many had hoped for: a system of universal health care. Leaving millions still uninsured and many more “underinsured” — a well-described and researched phenomenon in which the possession of health insurance still leaves individuals and families with dangerous financial liability when illness strikes — the ACA falls well short of the standard of universal health care as it is understood elsewhere in the social democratic world.
But more broadly, when we consider the ACA through the lens of political economy, an even more concerning narrative emerges, one that says even less about the triumph of social democracy and more about the sharp shift of the political center and the disintegration of the New Deal left. For the law fundamentally leaves intact a system of health care predicated, as we shall see, on key neoliberal health care beliefs, for instance the “moral hazard” of free care, the primacy of health consumerism, and the essentiality of the private health insurance industry.
This is not, however, an acute development: indeed, as we survey the last half-century, a long, slow, yet unambiguous neoliberal turn in the political economy of American health care becomes evident, during which the window for true universal health care — wide open as recently as the 1970s — has been slowly closed simultaneous to a historic rise in inequality and an unprecedented expansion of corporate power.
These developments are, of course, manifestations of a single transformation. Yet the neoliberal revolution of the political economy of American health care remains inadequately contextualized, requiring much deeper analysis and demystification — particularly in light of parallel changes unfolding in other nations throughout the world — if it is to be understood.