Involvement of employers in the provision of health care in the United States has a long history. Employer-mediated health insurance has certain advantages compared to an individual market for health insurance. Employment-based insurance reduces the risk of adverse selection, allows workers to benefit from the expertise and buying power of the employer, and helps ameliorate cognitive biases that might lead workers to under-insure. Prior to passage of the Affordable Care Act (ACA), ERISA did little to affirmatively regulate the content of health benefit plans, and ERISA’s broad preemptive reach posed a significant obstacle to states attempting to impose content controls. The passage of the ACA and its conforming amendments to ERISA changed matters importantly but not completely; various ACA reforms now affect benefit plans directly or indirectly, while leaving largely in place ERISA’s overall scheme of regulation. Future reform efforts – whether single-payer (Medicare for All) or a public option – may very well change that, but for now ERISA retains its potency as a health insurance regulatory statute.

Chapter 11 focuses on the adverse selection problem in the health insurance market, which is sometimes referred to as the “death spiral.” First, the concept of “uninsurable” individuals is developed and the rationale for eliminating differential pricing based on pre-existing conditions (experience rating) is explored. Then the chapter discusses the consequences of this choice: the adverse selection problem. Finally, alternative solutions to adverse selection are explored – both single-payer systems and market-based solutions such as the Affordable Care Act. The end of chapter supplement explores the historical reasons for differences between the health insurance system in the United States and the system of a close ally, the United Kingdom.

The financial burden of the opioid epidemic can be measured in trillions of dollars. Although treatment of substance use disorders can also be expensive, multiple cost–benefit analyses have demonstrated that treating addiction is cost-effective when compared to addiction-related expenses. Inpatient treatment tends to be more expensive than outpatient, and the actual cost of treatment varies by country. In addition, insurance status can play a significant role, especially in countries that do not offer universal health care. Unfortunately, there have been multiple victims of a scheme known as body brokering, in which vulnerable individuals are exploited for their insurance benefits. Therefore, it is important to find a reputable substance abuse program before entering treatment.

This chapter considers disparities in the quality of healthcare Black patients and White patients receive. One major cause of these disparities is that healthcare in the United States is basically a privately financed system. This makes access to necessary healthcare more difficult for Black Americans, because they are, on average, economically disadvantaged. Another factor is that American healthcare is still largely separate and unequal. Black patients are often treated at lower-quality medical facilities. Even within the same facilities, they frequently receive poorer care. Systemic racism within medicine also creates practice that contributes to racial healthcare disparities. One example of this is the widespread use of flawed diagnostic algorithms that reflect racist myths about the bodies of Black people; another is algorithms that systematically underestimate the health needs of Black patients. In addition, unique educational and financial challenges to entering medical professions faced by Black people and hostile institutional and professional climates that discourage Black trainees and practitioners have created serious shortages of Black healthcare professionals. This has numerous negative consequences for Black patients. Thus, racial healthcare inequities reflect both the nature of contemporary political, economic, and social structures in the United States and practices within medicine that seriously disadvantage Black patients.

In the first chapter in Part III, Frances Lee shifts the focus from elections to governing in the context of contemporary American politics. She examines the strategies of coalition leaders in Congress, who now operate in a world of highly polarized congressional parties. She scrutinizes the two major legislative efforts of the 115th Congress (2017-18): tax reform and the repeal and replacement of the Affordable Care Act. Lee finds that coalition leaders used many of the same techniques as in earlier periods. In particular, coalition leaders substantially modified their proposals to reduce the costs imposed on the constituents of legislators whose votes they needed. Similarly, leaders deployed procedural tactics to break the linkage between Congressional action and painful policy effects. These efforts were successful on tax reform but ultimately failed with the efforts to repeal the ACA, and Lee finds the failure was related to the traceable costs of the proposed policy change. She concludes that although polarization has arguably created new challenges for enacting major legislation, the strategies of coalition builders exhibit a good deal of continuity.

Opening Part I, Josh Clinton, Michael Sances, and Mary Sullivan examine the extent to which constituents evaluate incumbents based on their policy actions in office. The authors focus on situations in which representatives cast a vote contrary to the constituent’s views and present two different analyses. First, they examine the universe of issues in the 2008-2017 Congressional Cooperative Election Study (CCES) surveys, which include items designed to relate constituents’ policy preferences to specific roll- call votes in the House. Second, they conduct an in-depth analysis of legislative activity around the Affordable Care Act (ACA), investigating how members of different demographic groups vary in holding House members accountable for policy positions. In both analyses, partisan labels exert a substantial, independent effect on voter evaluations, but issue positions nonetheless matter. Moreover, the ACA analysis indicates that policy effects are larger among wealthier individuals. The findings imply that despite the increasing role of partisanship in U.S. elections, issue representation remains an important force in voter evaluation of incumbents.

The Progressive movement, the New Deal, and America’s involvement in two world wars encouraged sounding the alarm interposition by states, even if not identified as interposition. The explicit invocation of the term “interposition” surfaced in the 1950s by opponents of integration who sought a constitutional basis for white supremacy and racial inequality, particularly in opposition to Brown v. Board of Education of Topeka (1954) in which the Supreme Court rejected ‘separate but equal’ school segregation. After the Supreme Court repudiated interposition and nullification in Cooper v. Aaron (1958), use of interposition and nullification-like efforts resurfaced in resistance to federal laws and policies including: the Patriot Act of 2001, the Real ID Act of 2005, and the Affordable Care Act of 2010. A version of interposition termed “Judicial Federalism” emerged in the 1990s as a constraint on federal legislative power with the “anti-commandeering” principle in Printz v. United States (1997). Moreover, forms of “uncooperative federalism” and neo-nullification have marked recent efforts of states challenging federal policies and laws even as they fall short of nullification.

In National Federation of Independent Business v. Sebelius, decided in 2012, twenty-six states as well as private individuals and an organization of independent businesses challenged the constitutionality of two key components of the Affordable Care Act. The Court upheld the individual mandate but converted the Medicaid eligibility expansion from mandatory to optional for states. Elizabeth Weeks’ feminist rewrite breaks down the public law-private law distinction to get beyond the traditional view of health insurance as a commercial product providing individual financial protection against risk and instead to view it as effecting a risk pool premised on cross-subsidization of the health-care “haves” by the health-care “have-nots.” Weeks also rejects the original opinion’s dichotomy between “old” and “new” Medicaid as an artifice evidencing a fundamental discomfort with extending public assistance to able-bodied people who are judged capable of providing for themselves on the private market. In their commentary, Mary Ann Chirba and Alice Noble assess the original opinion and Weeks’ feminist rewrite in terms of their concrete effects on women’s lives.

As the 2020 Democratic primaries heated up in September 2019, the Center for Deliberative Democracy gathered 523 voters, designed to be a representative sample of the electorate, in a room in Dallas, Texas for three days for an experiment called “America in One Room.” Researchers pre-polled the participants for their views on a range of controversial political issues, from immigration to the environment to health care. Then, over the weekend, these 523 “citizen delegates” immersed in conversation in small groups and plenary sessions and with field experts and candidates on these topics. At the end, they were asked their views again. On some topics their views changed wildly from beginning to end. One where it did not was health care’s public option. At the beginning, just over 67 percent favored the idea that “[e]veryone should be able to buy a public plan like Medicare,” and at the end just over 71 percent did. With asked the same idea with respect to people age 55 or older, the idea was even more popular: 72 percent at the start and 78.5 percent at the end. People love the idea of a public health insurance option.

In late 2009, in an event space beneath the US Capitol plaza, a small celebration centered on a big decision. The Majority Leader of the US Senate, Nevada Democrat Harry Reid, announced he would support the inclusion of a public option in the health-care bill that would soon be considered on the Senate floor. As one of the policy experts who had pushed for the public option, I was in the audience – gratified that Reid had decided to fight for the goal yet unsure of what would come next. Earlier in the year, the House had passed its own health legislation, which included a Medicare-like public option. But from the moment it had become a major element of Democratic campaign proposals during the 2008 presidential race, the public option had been controversial – viewed as a step too far not only by Republicans and the medical industry, but also by many middle-of-the-road Democrats. Now, in signaling he would back it, Reid was also suggesting he could convince skeptical Senate Democrats to go along.

Chapter 5 examines the effect of disagreement with specific Supreme Court ruling on support for both narrowly and broadly targeted Court-curbing. The chapter presents results from a national panel survey with waves surrounding some of the most important rulings in the contemporary era, including 2012’s health care ruling (NFIB v. Sebelius, upholding the Affordable Care Act), 2013’s rulings on the Voting Rights Act (Shelby County) and same-sex marriage (Windsor), and 2015’s landmark ruling declaring a constitutional right to same-sex marriage (Obergefell v. Hodges). The results demonstrate that citizens’ support for Court-curbing changes as a function of agreement and disagreement with salient rulings. The chapter also demonstrates that right-wing citizens are consistently more supportive of Court-curbing throughout the 2012–2016 period, suggesting that blockbuster liberal rulings during this period have had a substantial impact on mass perceptions of the Court’s ideological tenor. We also report the results from two original national survey experiments which show that the effect of policy disagreement is larger for narrow than broad Court-curbing.

Throughout American history, protecting states’ rights within federal health reform laws has served purposes other than the needs of the poor, such as excluding those deemed undeserving of assistance, the “able-bodied.” This chapter explores the role of federalism in health reform, paying particular attention to the importance of universality in programs meant to aid the poor, such as Medicaid. American federalism is dynamic, involving separate state negotiations with the federal government rather than the fixed dual sovereignty imagined by the Supreme Court. Such negotiations lead to variability, which in health care may lower the baseline for reform-resistant states and thus the nation as a whole. This is especially significant when the federal government attempts to improve conditions nationwide, as it did with the Affordable Care Act’s (ACA’s) universal health insurance coverage. The example of Medicaid expansion under the ACA demonstrates how state variability can improve coverage but also jeopardize it; keeping states in the picture sometimes results in restricting access to the safety net rather than strengthening it. The debates of the twentieth century about the role of government in health and who is deserving of aid are bound to repeatedly arise without fully gauging federalism’s mixed effects in health reform.