One of the main messages of The ten years war, Jonathan Cohn’s excellent story of the Affordable Care Act (ACA), appears in the last chapter: “The Affordable Care Act is a very flawed, hopelessly compromised and woefully incomplete attempt to establish a fundamental right that already exists. in all other developed countries. It is also the most ambitious and important national legislation to pass in half a century, a big step towards a more perfect and more humane union as well. “
Cohn’s other key message, spelled out more succinctly in a March 22, 2021 article in the Atlantic (adapted from the book), is that the ACA became law because Democrats were willing to do the hard work of compromising and turning policy into legislation. It was not repealed because Republicans were unwilling or unable to do this job.
Cohn is well known to anyone following a health policy. A senior national correspondent at The HuffPost and former editor-in-chief at New Republic, he followed the ACA before its creation. He is an excellent writer and has written a very readable and informative book.
The ten years war is divided into three parts. The first describes past health care reform efforts, focusing on the failure of the Clinton plan. He also recounts the “Romneycare” health care reform in Massachusetts, which gave hope that bipartisan reform might be possible and provided a model for much of the ACA. Finally, he describes the 2008 presidential campaign, which laid the foundation for the ACA.
Part Two details the drafting and legislation of the ACA in the House and Senate from 2008 to 2010. Although Democrats held substantial majorities in both houses, including a majority of sixty votes in the Obstruction-proof in the Senate For some of that back then, Democrats ranged from moderate conservatives to single-payer liberals; mending a consensus bill was a huge effort that left no one completely satisfied. Additionally, a serious but ultimately unsuccessful effort was made to garner bipartisan support for the bill, delaying the process. The death of Senator Ted Kennedy (D-MA) early in this process made the job even more difficult, and the loss of the 60th Senate vote in early 2010 nearly destroyed the effort. But in March 2010, everything happened.
The third section deals with Republicans’ efforts to destroy the ACA from 2010 to 2017.The first two chapters of this section describe the two Supreme Court cases in which opponents tried to bring down the ACA. The first of these cases, National Federation of Independent Business c. Sebelius, upheld the individual mandate as a tax, but said mandatory Medicaid extensions were unconstitutional, leaving millions of low-income Americans uninsured in states that chose not to expand. The second case, King v. Burwell, found that the Federal Stock Exchange, or Marketplace, which existed in most states, could provide premium tax credits just like state scholarships and thus saved the premium subsidies, which were essential to the expansion of coverage.
Much of the remainder of Section Three deals with Republican efforts to repeal and replace the ACA. Cohn demonstrates that Republican efforts were doomed because it was clear that repealing the ACA’s coverage provisions would lead to a massive increase in the number of uninsured people, and Republicans had no plans for an alternative which would solve this problem. Republicans were determined to repeal Barack Obama’s signature, but had no “replacement” of their own.
The ten years war is indeed a political story. It details the Democratic political leaders who crafted the bill and the Republican politicians who attempted to destroy it, often recounting their health policy backgrounds and experiences with the health care system. It also describes the legislative and presidential assistants who did much of the work of developing and implementing the bill. Finally, it analyzes the legislative processes by which the ACA was adopted and nearly repealed.
The book has much less to say about the regulatory processes by which the ACA was implemented. It only briefly touches on the failure of the HealthCare.gov website in 2013 and the “if you love your health plan, you can keep it” fiasco, which resulted in the creation of “grandma” plans. Although it deals with the NFIB and King v. Burwell case, it says nothing about the many other cases that have been brought against the ACA and its regulations, including legal battles over contraceptive coverage, which still continue. In addition, it focuses almost exclusively on the Title I coverage and insurance provisions of the ACA and the Medicaid extension provisions of Title II. He says next to nothing about the remaining eight ACA titles, which have resulted in dramatic changes throughout America’s healthcare system. Finally, by limiting himself to the first ten years of the ACA, it fails to take into account the later major efforts of the Trump administration to undermine the ACA through executive action.
But attempting to cover all of these topics would have resulted in an unreadable length of book and would have clouded Cohn’s main theses on ACA politics. As it stands, Cohn has produced the most readable and comprehensive ACA story to date, a must read for anyone who wants to understand this story.