Obamacare and the Politics of Universal Health Insurance Coverage in the United States

In the USA, universal coverage has long been a key objective of liberal reformers. Yet, despite the enactment of the Patient Protection and Affordable Care Act (PPACA) (commonly known as ‘Obamacare’) in 2010, the USA is not set to provide health care coverage to all, even if and when that reform is fully implemented. This article explores this issue by asking the following question: Why was a clear commitment to universal coverage, the norm in other industrialized countries, excluded as a core objective of the PPACA and how has post-enactment politics at both the federal and the state level further shaped coverage issues? The analysis traces the issue of universal coverage prior to the debate over the PPACA, during the 2008 presidential race, and during consideration of the bill. The article then looks at the post-enactment politics of coverage, with a particular focus on how states have responded to the planned use of the Medicaid programme to expand access to care. The article concludes by discussing how an explanation of the limits of the PPACA, in terms of both its commitment to universal coverage and, more importantly, the failure to provide comprehensive health insurance to all, requires an understanding of complex institutional and policy dynamics.