During most of 2009 and the first quarter of 2010, a passionate debate divided Americans over the future of their health care system. At the centre of this debate was the paradox that the United States spends a greater portion of its GDP on health care than any other nation, while leaving more than 45 million people without any insurance coverage whatsoever. Signed by President Obama in March 2010, the Patient Protection and Affordable Care Act addresses these two related issues: cost control and coverage. On the one hand, this new legislation attempts to control cost increases through a number of policy changes, including the creation of a permanent Medicare commission tasked with initiating cost saving measures on a regular basis. On the other hand, through the expansion of the Medicaid social assistance program and the imposition of an ‘individual mandate’ affecting most of the population, the 2010 law should dramatically increase coverage, although falling short of delivering universal coverage (more than 5 per cent of the population will remain without coverage by the time the legislation is fully implemented). The most important health care reform enacted in the United States since the advent of Medicaid and Medicare in 1965, the main provisions of the Patient Protection and Affordable Care Act should take place gradually over the rest of the decade, and the battle over its implementation has already began. Perhaps more important, Republicans have promised to repeal the legislation if they ever have the opportunity to do so, and lawsuits have been filed by many Republican states to challenge the law's constitutional validity.

Considering the fierce nature of this highly contentious debate, Oxford University Press made exceptional efforts to get this book out before the mid-term elections of November 2010. Normally, university presses can take up to a year (and sometimes more) to publish a book that has already been accepted for publication, making the publication of this book less than six months after President Obama signed the act even more impressive. Targeting a broad audience, this concise and accessible book is written by two prominent political scientists who have published extensively about US health care reform: Lawrence Jacobs (University of Minnesota) and Theda Skocpol (Harvard University). Knowing ‘something big’ could happen, these top scholars began their research long before the enactment of the 2010 reform, which allowed them to conduct interviews and collect other data well before the Senate bill was signed into law. In this book, Jacobs and Skocpol explain how this reform came about before assessing its socio-economic consequences and the political challenges stemming from its implementation, which is complicated by strong interest group pressures and provisions granting significant policy autonomy to the fifty states.

Although this is a ‘trade book’, it draws on the existing scholarship about US social policy and political institutions, which helps the authors account for the many obstacles President Obama and his Democratic allies in Congress faced during the reform process that lasted nearly a full year. Clearly, the fragmented nature of US political institutions complicated the reform process while forcing federal lawmakers to compromise over policy issues in order to satisfy ‘moderate’ and ‘conservative’ Democrats in the House of Representatives and, especially, the Senate.

Despite these compromises, Jacobs and Skocpol believe that the 2010 legislation is a major step forward in terms of both cost control and access. According to them, the vast majority of Americans will benefit from this complex reform. In the end, the wealthier population and the health industry will cover most of the costs generated by the reform, while middle-class and low-income citizens should get better and more affordable access to care.

Because the book is aimed at a broad audience, Jacobs and Skocpol try to dispel many of the myths about the reform propagated by right-wing ideologues like Sarah Palin. In their attempt to ‘set the record straight’, Jacobs and Skocpol do not say enough about the flaws of this legislation, which will not bring about universal coverage and, according to many health experts, may not do enough to contain cost increases. Moreover, the discussion about abortion – a key ‘side issue’ during the legislative debate – is barely discussed, which is problematic because it caused major headaches for the Democratic leadership in the House of Representatives who had to deal with pressures from ‘pro-choice’ feminists and anti-abortion ‘blue dog’ Democrats opposed to any use of federal money to fund abortion procedures. A final flaw in this book is that the historical background is too limited in scope to help readers less familiar with the US health policy system grasp the broad meaning of the reform.

Despite such minor imperfections, this is an excellent and well-written book that should help citizens, students and scholars alike understand the nature of the most important US health care reform in more than four decades. In addition to the main text, the book features an index, a detailed timeline, and a useful ‘Glossary of Key People, Groups, Legislation, and Health Care Terms’. Overall, this engaging book is essential reading for anyone interested in the present and the future of US health policy.