Health Affairs offers insight into healthcare reform's murky future

Healthcare reform might be law, but "the bitter U.S. war over comprehensive health reform is far from finished," Harvard political scientist Theda Skocpol warns in the new issue of Health Affairs. The July issue of the health policy journal features several articles on healthcare reform's implementation, including Skocpol's piece on "the political challenges that may undermine health reform."

The author dismisses well-publicized efforts to overturn the law in Congress or the courts and writes instead that "a far more serious effort to undermine the law will come about through challenges to various administrative arrangements, taxes, and subsidies to fund expansions of coverage." She suggests business groups and wealthier individuals — particularly elderly votes worried the bill's cost could undermine Medicare — will press for "lower taxes, looser regulations, and reduced subsidies for low-income people."

In the piece, Skocpol points out that Social Security almost died during the 1940s despite its passage in 1935, as scheduled taxes and benefits were interrupted during World War II; only during the next three decades did taxes resume.

She expects opponents of reform to continue to chip away at fees, taxes and insurance regulations. And she questions whether state officials will provoke a "race to the top" through their insurance exchanges or, on the contrary, undercut adequate coverage and effective regulation.

"We can predict that much of the intended redistribution will be reversed, because it is so easy and tempting for public officials of either party to enact tax breaks for the rich or to adjust regulations and subsidies as demanded by well-heeled business interests," Skocpol writes. "Each individual change will seem small enough so that particular legislators, even Democrats, can rationalize their votes, but the changes will add up."