Vidhya Alakeson on US healthcare reform

The theatre of politics has been on full display in Washington of late. Last week, the House of Representatives voted to repeal the Patient Protection and Affordable Care Act passed in March last year that, among many other things, will ensure that more Americans have health insurance coverage. The vote was largely symbolic for the new Republican-controlled House. For the repeal to become law, it would have to be passed by the Senate, where Democrats have held onto a slim majority, and would finally have to be signed into law by the President. Even with a Republican controlled Senate, the repeal would stall at President Obama’s desk.

Why the gesture? The Tea Party movement that accounted for the success of many of the Republicans elected to the House of Representatives in November last year has little more to its policy platform than small government, low spending, and individual freedom. For tea partyers, the Affordable Care Act came to represent the ever growing reach and ever expanding budget of the federal government in Washington. Repealing the  legislation was an electoral promise that House Republicans could not actually keep but they could use the drama of a repeal vote to make their point. What they could not have predicted was that the shooting of Gabrielle Giffords, a staunch supporter of healthcare reform, would make their gesture seem not only hollow but dangerously divisive.

While the repeal was never more than a gesture, some supporters of health reform have raised concerns that Republicans will stop progress by blocking funding for certain parts of the legislation. It is a strange feature of American law-making that a programme can be passed into law without being funded. Of course, without any funding, the programme cannot be implemented. Fortunately, the funding for the most significant parts of the Affordable Care Act are written into the bill and do not depend on the annual cycle of congressional appropriations. At the margins, the Republicans could block funding for some pilot projects but the big changes such as the introduction of state-based health insurance exchanges and coverage for those with pre-existing conditions are not under threat.

Washington theatre continued this week with the State of the Union address, the President’s annual speech to Congress and the nation. For the first time ever, Democrats and Republicans sat side by side rather than at opposite ends of the chamber – a small gesture of recognition that the political divide in Washington has become destructive and the people of Tuscon paid the price. Overall, healthcare took a back seat in this year’s State of the Union speech, with deficit reduction, economic growth and reducing unemployment taking centre stage. When healthcare did get mentioned, the tone was conciliatory. The President agreed to listen to Republican ideas to improve the Affordable Care Act but stood firm against repealing the law altogether and starting again. As Obama’s poll ratings steadily improve, the White House must hope that, if the implementation of healthcare reform can continue to the point where some Americans start to see the benefits, the President will reap the benefits just in time for the 2012 election.

Vidhya Alakeson is the director of Research and Strategy at the Resolution Foundation and works as a freelance consultant on issues related to personalisation in health and social care. She was a 2006/7 Harkness Fellow in Healthcare Policy based in Washington D.C. and then worked for two years as a Policy Analyst at the U.S. Department of Health and Human Services.