The recent passage of health care reform was certainly historic—it is the largest piece of progressive domestic legislation to become law in forty-five years (since Medicare). After many desultory and dispiriting months, President Obama can now plausibly say that “that hopey-changey thing,” as Sarah Palin mockingly referred to his grand campaign theme in a February 2010 speech, is well underway.
But to what degree will the victory change political dynamics in the capital? Here, the potential impact of the victory probably can’t match the historical importance of the accomplishment. Just as liberal despair in recent months was shortsighted and overwrought, the liberal euphoria that came with the bill’s passage is similarly worth examining, for three reasons.
First, the passage of the bill into law marks a beginning rather than an end. The law’s most conspicuous elements—the creation of health insurance exchanges, the subsidies for coverage, the full range of new regulations governing insurance companies—won’t take effect until 2014. Even then, myriad complex questions of implementation will need sorting out.
The most important of these will surround the structure of and rules governing the new exchanges the bill will set up so that small businesses and individuals can purchase coverage at competitive prices. Whether the exchanges really work will depend, for example, on the success of “risk adjustment” policies, so that the plans offered in the exchanges won’t vary too greatly in what they charge and offer consumers. This is why many liberals would have preferred one national exchange rather than state or regional exchanges—the users of one national exchange, with its much larger risk pool, would have far more power to negotiate costs with insurers.
There will be dozens of such questions to be answered by future bureaucrats, and inevitably, there will be misjudgments and unforeseen difficulties. Ferocious political opposition will continue. Not much mentioned during the debates over the bill—although clearly a source of opposition to it—was the fact that it will add to the Medicaid rolls an estimated 16 million relatively poor people, many of them black or Latino. This is a change that will be criticized by some state governments, which administer Medicaid jointly with the federal government. But there will also be future disagreements over implementation within the group of people who want to make the law work. The passage of this bill merely starts a policy debate that will continue for years.
Second, there is the matter of the political consequences of this bill—and the way it was passed—for other Democratic initiatives. It is natural to think that a crucial legislative victory will embolden the winners to push ever onward, aiming their mighty sword at fresh targets. Progressives will certainly hope that this will be the case—with …