Editor’s Note Understanding Big-Bang Reform

If you are a health policy junkie in the United States, you were likely engrossed by the Supreme Court’s oral arguments on the constitutional-ity of President Barack Obama’s health care reform law—the PPACA. It turns out, however, that you don’t have to be a junkie to have tuned into the Supreme Court hearings. Given that Americans have not been able to pass significant health reform legislation since Medicare in 1965 and this bill promises to provide close to universal coverage, it’s no wonder Americans are listening. No doubt some are watching because they fear the loss of insurance coverage they had finally hoped to secure. However, we also know from the polls that some other Americans are watching because they are incensed by the compulsion to purchase private insurance— the individual mandate. Indeed, in a conversation I had with a colleague about the states ’ lawsuit against the federal government, she asked: “Should Obama have known this? Should he have known that the indi-vidual mandate would be challenged and would endanger the bill?” Anne-Laure Beaussier’s detailed account of the passage of the PPACA is a good response to this question, and much more. She reminds us that the changes enacted in March 2010 were the result of ideas discussed for more than two decades among elected officials and health care experts across both sides of the political aisle, but primarily emerging from conservatives as a way to preserve the private health insurance market and promote competition. That Obama, or anyone else from the Demo-cratic leadership, did not take seriously a constitutional challenge abou