The terms used to describe the Patient Protection and Affordable Care Act (ACA) of 2010 seem so polemical and exaggerated — private takeover, socialized medicine, Obamacare, death panels — that many questions arise. Is this reform truly historic? Is it a big-bang reform or classic American incrementalism, building slowly and persistently on the existing system? Are there clear historical roots in this reform, and are there parts of the ACA that will potentially take the United States in a new direction? These are the questions addressed by the essays in this section. James A. Morone provides a broad historical look and shows us how social insurance, Lockean liberalism, a broken Congress, and our need for a neo-Progressive technical fix have shaped the U.S. health care system and this particular reform. Kimberly J. Morgan and Andrea Louise Campbell explain how the ACA is yet another example of the American penchant for delegated governance. Although technical feasibility and efficiency are often used to explain this preference, Morgan and Campbell show how classic liberal views for minimal government and interest-group mobilization are at the root of our reliance on delegation. Marie Gottschalk helps us understand why Democrats abandoned the movement for a single-payer system in lieu of a public option. She examines why this approach failed, as well as its costs and implications. In a response to the hyperbolic descriptions above, I then demonstrate how the ACA is neither extreme government takeover nor private privilege but is consistent with an established pattern of building up the U.S. health care state through investments in private provision and infrastructure, then hiding such investments from view. Finally, as a seasoned health policy analyst and herself a political player, Judith Feder considers the political and policy significance of the ACA in light of the long-term struggle to enact health care reform in the United States.

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