Health reform is now the law of the land. On March 23, 2010 President Barack Obama signed the Patient Protection and Affordable Care Act, and one week later he followed with modifications in a budget reconciliation bill.

The legislation, which will result in an estimated 32 million uninsured Americans getting health coverage by 2019, will begin to redesign a fragmented, uncoordinated and highly expensive health care system. The new law was the fulfillment of a goal sought by reformers, with varying degrees of intensity, since Theodore Roosevelt introduced the idea of coverage for all in the 1912 Progressive Platform.

As President Obama noted, it was a “remarkable and improbable” achievement. Yet in our current polarized environment, it remains fraught with political and policy uncertainties that could shadow implementation in the years to come.

Historically, our discussions of national health reform focused on coverage. This time, the Obama administration and its allies effectively made the case that health reform is greater than coverage alone. Coverage, cost and quality, they argued, are intrinsically entwined, and cannot be addressed by piecemeal or incremental solutions.

Our system, rooted in a mid-20th century acute care model, does not adequately meet the health care or economic needs of the 21st century, where the overarching medical challenge, and expense, is due to chronic disease in an aging population.

Reform advocates argued that the cost of inaction outweighed the cost of action, and that state and federal governments, large and small businesses, and ordinary American families needed relief from the unrelenting and unsustainable upward march of health care costs. And they convinced a majority of lawmakers, albeit a narrow Democrats-only majority, that covering the uninsured in a revamped and modernized high quality health care system is the morally and fiscally responsible American way. 

Health care reform is difficult because it’s big and complicated, with lots of moving parts and unintended consequences. It affects one-sixth of the economy, and touches every doctor, hospital, and community. It’s also hard because even in less volatile political times Washington debates are not always about health care per se, but about politics, power, and the size and reach of government. 

The battle over health care did not end with the votes in the House and Senate. It will play out in the political campaigns of 2010 and 2012 and possibly beyond – in state and federal courts, and in Congress and statehouses charged with setting up exchanges, writing and implementing regulations, and appropriating funds so that health reform becomes not only a law but a reality. 

The 18 months of debate and the opening phase of implementation were shaped by an interesting paradox. As Prof. Robert Blendon of the Harvard School of Public Health has explained, many in the U.S. are skeptical about “health reform” but support many of reform’s components, such as creating health insurance exchanges, subsidizing the poor, or requiring insurers to cover people with pre-existing conditions. Reform’s success in the long term will be determined in part by whether and when the American public decides that health reform is the sum of its reasonably popular parts.

To read the full report with references click here.

Originally written by Joanne Kenen, New America Foundation. Updated April 2010 by Joanne Kenen. (Research assistance from Meredith Hughes and Allison Levy.)