That’s the title of my essay in the January-February 2014 issue of Foreign Affairs. You can read it at foreignaffairs.com. It’s free; you simply have to register. Here’s the opening:
Since March 2010, when U.S. President Barack Obama signed the Affordable Care Act into law, the ACA has been at the center of American politics. Tea Party activists and their allies in the Republican Party have tried to stymie the law at nearly every turn. The Republican-controlled House of Representatives has voted more than 40 times in favor of repealing or defunding it, and last October the House allowed a partial shutdown of the federal government in an attempt to block or delay the law. The controversy surrounding the ACA shows no sign of ending anytime soon.
Obamacare, as the law is commonly known, is the most significant reform of the U.S. health-care system in half a century. It aims to increase the share of Americans who have health insurance, improve the quality of health insurance plans, and slow the growth of health-care spending. But the fight over the law is about more than just health-care policy, and the bitterness of the conflict is driven by more than just partisan polarization. Obamacare has become the central battleground in an ongoing war between liberals and conservatives over the size and scope of the U.S. government, a fight whose origins stretch back to the Great Depression and the New Deal….
The ACA represents another step on a long, slow, but steady journey away from the classical liberal capitalist state and toward a peculiarly American version of social democracy. Unlike in, say, northern Europe, where social democracy has been enacted deliberately and comprehensively over the years by ideologically self-aware political movements, in the United States, a more modest and patchy social safety net has been pieced together by pragmatic politicians and technocrats tackling individual problems. Powerful forces will continue to fight those efforts, and the resulting social insurance policies will emerge more gradually and be less universal, less efficient, and less effective than they would otherwise have been. But the opponents are fighting a losing battle and can only slow down and distort the final outcome rather than stop it. Thanks to a combination of popular demand, technocratic supply, and gradually increasing national wealth, social democracy is the future of the United States.
Lane Kenworthy 
Given that the ACA is barely up and running, isn’t it a little premature to celebrate its success ?
ACA may, or may not, be a huge improvement (certainly, community rating [no pre existing condition ban] is huge, huge, but over all we really don’t know how it is going to work.
In todays N Y Times, there is an article about how if your salary goes up by 3 or 5 K/year, you can loose 6 or 10K in subsidys – a small salary increase is a net decrease in household income
for sure, some bright CPAs are gonna be cooking up all sorts of deferred salary schemes where you get paid in some special way that doesn’t count torward ACA income.
can anyone say the CPA and lawyers employment act of 2010 ?
PS: the battle over gov’t size goes back at least to the administrations of Jefferson and Madison; aside from internal improvements, there was a huge debate as to the propriety of a standing army in the absence of a declared ware
I generally agree with every section of your essay but “Risks and Rewards”, as I doubt that a bewildering array of minor tweaks to the system will demonstrate much in the way of either political legs or bureaucratic efficiency. A universal basic income would solve both of these problems elegantly. Otherwise, I applaud you for an excellent piece.
It’s an interesting thought experiment, but the main linchpin to your thesis is that the Republican party turns into a European style center right party which, after having seen the beating heart of it run Arizona for 4 years, I don’t see a pathway for anytime soon. Mitt Romney ran on one of the most conservative platforms in history (anti immigration reform, no new taxes, far right on social issues, hawkish foreign policy) and was defeated rather resoundingly yet the GOP blocked immigration reform, gun background checks, economic stimulus, and shutdown the government in the following year. Not only that but the “lesson” Republicans learned was that they need a more conservative nominee. I would argue that currently the Democrats bear much more resemblance to European center right political parties, particularly if you look at the Tories in England (socially progressive and economically moderate). My other counterargument would be many of the policies you propose have been proposed (VAT, removing the home mortgage interest deduction to finance a more generous welfare state) and there is very little interest in either party because it causes real pain to the middle class for an uncertain benefit. Unfortunately the most difficult thing to overcome in American politics is status quo bias.
I am not sure an ageing population will become more social democratic.
The expressive voter is now a fiscal conservative. Voters booing fiscal deficits really started at the end of the 1990s.
With an ageing population, older voters do not want large debt servicing bills from fiscal follies of decades gone to limit the health and pension funding to them when they are elderly.
The major voter demographic is more and more voters are swinging voters. There are fewer and fewer rusted-on voters.
The other voter demographic is the average age of voters is rising. Older people are wiser in the ways of the world and vote for right-wing parties more often for that reason.
There is no gender analysis here. Women change their vote more often than men depending on whether they are single, married, divorced or a single mother.
Yes, it’s a big reform. It’s main two consequences: health insurance coverage is increased, while health care coverage is decreased. See e.g. Narrow Networks: How They Affect Doctor Specialties for more