And the winner is...

After months of sparring between Democrats and Republicans over healthcare reform, it is the American public that is set to emerge victorious following President Obama’s controversial restructuring of the health sector.

“We proved that this government - a government of the people and by the people - still works for the people”

It was, remarked one observer, like a scene from the civil rights era half-a-century ago. Rallies outside the Capitol are typically orderly affairs, with speeches and well-behaved crowds; this one had baton-wielding police separating furious demonstrators from the members of Congress making their way to vote on the divisive issue of healthcare reform. Racist and homophobic slurs were repeatedly hurled at pro-reform lawmakers walking by; another was spat upon. Democratic Whip Jim Clyburn, who led fellow black students in integrating South Carolina's public facilities a half century ago, called the behavior shocking. "I heard people saying things today that I have not heard since March 15, 1960, when I was marching to try to get off the back of the bus," Clyburn told reporters. Clearly, the issue of healthcare reform is bringing out the nastier side of American politics.

Indeed, such venomous exchanges have been symptomatic of President Obama's attempts to push through the healthcare restructuring plans that provided his presidential campaign with such a strong and popular platform. The debate should have been about doctors, patients, insurance, drug companies and coverage; instead, much of the attention has been focused on the legal and constitutional processes required to get any potential reform bill passed into law.

Make no mistake: this has been an exhausting campaign for people on both sides of the political divide. Back in December it had only seemed a matter of time before comprehensive healthcare reform became a reality. But Republican Scott Brown's defeat of Democratic candidate Martha Coakley in a Senate special election in Massachusetts - one of the Democrats' safest seats - sent shockwaves through Washington and re-energized GOP activists. Almost overnight, the passage of healthcare reform had gone from being a mere Congressional formality to a mathematical uncertainty as the Democrats lost the all-important 60-vote super-majority that would have virtually guaranteed the bill's success. And while polls demonstrated overwhelming bi-partisan support for individual components of reform, the Republicans seized upon Brown's victory as being representative of public unease with the process by which the arguments were being won.

The result has been months of wrangling, sniping and political maneuvering. But in the last few weeks, President Obama has taken strong action to bring what has been a year-long legislative showdown over his top domestic priority to a close. "Everything there is to say about healthcare has been said, and just about everybody has said it," he asserted at a recent briefing. "Now is the time to make a decision about how to finally reform healthcare so that it works, not just for the insurance companies, but for America's families and America's businesses."

And on March 21, he finally got his wish. The healthcare reform legislation passed by the House of Representatives by a vote of 219-212 effectively ends a year's worth of political horse trading and lobbying, and gives an additional 32 million Americans access to basic health insurance by 2019. And even though it is projected to cost $938 billion over the next decade, it is also set to reduce the budget deficit by $138 billion over the same period, according to the Congressional Budget Office.

It is the first major revamp of America's costly and unwieldy health insurance system in decades, and Mr Obama has been keen to stress that the victory is one for America as a whole rather than one for him and his party. "I've got a whole bunch of portraits of presidents around here, starting with Teddy Roosevelt, who tried to do this and didn't get it done," the President said during a televised inquisition by Fox News in the Blue Room of the White House as the campaign neared its climax. "But the reason that it needs to be done is not its effect on the presidency. It has to do with how it's going to affect ordinary people who right now are desperately in need of help."

Indeed, the true winners of the reform process could be the American public itself. Over 94 percent of all non-elderly Americans will have access to health insurance by 2016, versus just 83 percent now. Health insurers won't be able to deny coverage based on pre-existing conditions. And generous subsidies will be available to lower-income families to help them get cover. The bill also expands eligibility for Medicaid as part of its coverage mechanism, as well as increasing Medicaid reimbursements, which will make it easier for patients on Medicaid to find doctors who take their insurance. The so-called 'donut hole' coverage gap in Medicare Part D plans is also set to be closed.

The influential American Public Health Association (APHA), for one, congratulated the House of Representatives on its historic decision. "For nearly a century, providing quality, affordable care to all Americans has eluded our grasp; today's vote, however, changes all that," said Georges C. Benjamin, Executive Director of APHA. "Passing this measure will strengthen our public health system, invest in prevention, improve the health of the American people and move us closer to providing comprehensive and affordable health coverage for all Americans."

There was support from the private sector, too. Gary Lauer, Chairman and CEO of eHealth, Inc. also sees the bill's passage as significant. "With final legislation awaiting the President's signature, strategies for implementation of reform and enrollment of Americans in health insurance coverage will be the next and most important order of business," he says. "We believe that the technologies that have been developed by private sector players are key to ensuring Americans find and receive the coverage this legislation would mandate."

Of course, the bill as it stands today is far from perfect. And according to Michael Cannon, Director of Health Policy Studies at the Cato Institute, it is unlikely that the health legislation signed into law by President Obama will look the same when it takes effect in four years' time. "It creates too many unstable situations that Congress will have to address," he says. For instance, under the new law, insurance companies will have to offer coverage to children with pre-existing conditions within the next six months. But it is not clear how much they will charge. And, Cannon says, young people and healthy individuals will have an incentive to drop their coverage now, knowing that they will be offered a cheaper alternative in the future. That could cause private health insurance markets to implode.

Such ambiguities mean the debate on the merits of the healthcare plan look set to run on well into the second-half of Obama's term - and possibly decades into the future. Insurance companies - despite gaining access to an additional 32 million taxpayer-subsidized customers (Forbes called the new legislation a "cash for clunkers program for HMOs") - are amongst those disenchanted with the move. "WellPoint is disappointed that after more than a year of debate, Congress has approved healthcare legislation that does little to reduce cost and improve quality - two important elements to building a sustainable healthcare system that provides affordable coverage for all Americans," stated Kristin Binns, a spokeswoman for Wellpoint, in the aftermath of the vote. "We will continue to advocate what we believe is in the best interest of our customers and the country - affordable, quality healthcare that is accessible to all." Likewise Jeffrey Kang, Chief Medical Officer at health insurance giant Cigna, believes the legislation only addresses part of the problems facing the healthcare system. "The bill really only deals with the coverage issues or the expanded access issues, and doesn't deal with the cost or quality issues," he says. "So you find the expanded coverage is financed by lots of increased taxes."

There is certainly a case to be made that reforms are going to prove costly. The overhaul is largely going to be paid for by cuts in Medicare, new taxes on investment income and fees on various industry participants that will almost certainly be passed along to the general public. And while government subsidies for people who cannot afford insurance and insurance exchanges to help people get insurance will not be operational before 2014, the increased costs will begin next year.

But despite continued opposition to the program of changes, the Democrats are entitled to feel that a significant victory has been achieved. A new Associated Press-GfK Poll finds a widespread hunger for improvements to the healthcare system amongst the American people, which suggests that Mr Obama has a political opening through which to push his plan. Half of all Americans say healthcare should be changed a lot or 'a great deal', and only four percent say they are happy with the status quo. Democrats hope that such a groundswell of support for change will be enough to counter the fact that more than 80 percent of Americans say it's important that any healthcare plan have support from both parties, and that two-thirds believe the president and congressional Democrats should keep trying to cut a deal with Republicans rather than pass a bill with no GOP support.

Such a scenario means the opinion polls over the next few weeks will make for interesting reading. Can success breed further success and enable the president to steam ahead with difficult laws on immigration and the environment? Or will the protracted nature of the healthcare battle leave his party feeling burnt out, beat up and short on favors to call in?

If the president himself is in any doubt, he's not showing it, preferring instead to concentrate on the historic significance of an achievement that has proven too great for every American leader before him. "At a time when the pundits said it was no longer possible, we rose above the weight of our politics," he said shortly after the bill was passed. "We pushed back on the undue influence of special interests. We didn't give in to mistrust or to cynicism or to fear. Instead, we proved that we are still a people capable of doing big things and tackling our biggest challenges. We proved that this government - a government of the people and by the people - still works for the people."

This article was first published in EHM magazine: www.executivehm.com/article/And-the-winner-is