It’s been a dozen years since then-Vice President Joe Biden used some salty language to tell his boss that the bill he was about to sign was a “big (expletive) deal.”

The bill was the Affordable Care and Patient Protection Act, the kind of comprehensive health care reform that had eluded Washington for half a century.

The wild debate it unleashed gave birth to the anti-government tea party movement, with organized crowds taking over congressional town hall meetings, shouting down senators and representatives with accusations and threats.

Now, 12 years later, Joe Biden is the president and some of the controversies of 2009-10 can be put to rest: For the most part, the critics have been proven wrong and the proponents have been proven right.

More people are covered with health insurance. And the worst practices of the insurance industry – such as denying policies to people with pre-existing conditions or dropping their coverage because they got sick – are now illegal.

But there is still a lot of work that still needs to be done. America still pays more for health care  than any other country, and gets worse health outcomes when compared to other developed countries.


Millions of Americans can’t afford to get sick, according to a survey by the Kaiser Family Foundation. One in 10 of us are carrying health care debt, run up even by people with insurance who can’t afford to pay the deductibles and co-payments required by their plan.

“Obamacare” did not bring on bureaucratic “death panels,” as the tea party warned, but it also did not revolutionize our complex health care system with a confounding array of public and private payers and providers, regulated by federal and state agencies.

Most health care is still delivered on a fee for service basis, which creates perverse incentives. Hospitals get paid to treat sick people but not for keeping them healthy.

Some promising pilot programs were included in the Affordable Care Act that created entities that would be able to capture some of the savings that came from avoided costs achieved by better health management, but are not leading to the hoped for revolution.

Roughly half of the population gets its coverage through employer plans, which are subsidized by a federal tax deduction, the largest single tax expenditure in the federal budget. This is unchanged since the passage of the Affordable Care Act, and creates a set of problems that are unique to Americans.

Our workers can get locked in jobs or blocked from starting a business because of the high cost of health insurance. With so many different insurance plans, the system becomes fragmented and expensive to administer.


And reliance on employer-provided plans reinforces economic inequality. Well-compensated employees get the best coverage, with the lowest out-of-pocket costs, while low-paid and part-time workers pay more for worse coverage.

There is still work to be done to improve a system that every single American will need at some point in their lives. Standing in the way of common sense, popular reforms is the political divisiveness that has shaped government since 2009.

As president, Biden was able to power through some of the obstacles by including increased subsidies in the $1.9 trillion COVID relief bill that passed Congress last year. But those were only temporary and set to expire this year.

Other programs that would lower health care costs, including having Medicare cover hearing aids and allowing the federal government to negotiate the price of the prescription drugs it buys, were lost when Biden could not win the support of two idiosyncratic Democrats in the U.S. Senate, or any Republicans.

With the midterm elections only eight months away, there is no time for a sweeping reform on the scale of the Affordable Care Act, but there may be a chance to fix some of what has been left undone.

If Biden can find a way to get that done in this political environment, it would also be a big, big deal.

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