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The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage by Jonathan Cohn is a nonfiction account of the political battles to create, and dismantle, the Affordable Care Act (ACA). Mr. Cohn is an author and journalist, writing mainly on US public policy.

Love it or hate it, the ACA seemed to have touched a lot of lives, some for better, some for worst. Morever everyone has an opinion on this legislation, much less one that is grounded in realism, mostly on the basis of political ideology regardless of facts (in my experience).

The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage by Jonathan Cohn sketches out the history of healthcare as a public policy from the 1970s to today; in addition to the battles fought in Washington DC about it. Furthermore Universal coverage, as Mr. Cohn points out, was at first a conservative idea. In addition, it aligns very nicely with ideals both Democrats and Republicans can agree on such as self-responsibility, business profitability, and fiscally responsible.

As a matter of fact, the author points out the both Presidents Richard Nixon and Ronald Reagan embraced universal healthcare enthusiastically. Additionally, the Republican Party, by far and large, embraced Romneycare’s individual mandate in Massachusetts (transferring the onus from small businesses, to the individual).

When President Barak Obama introduced the ACA as his landmark legislation, he found himself defending Republican initiatives against those who previously championed them. The ACA, as we all know, was not perfect. Furthermore, it included some unbelievable lazy passages which were fodder for lawsuits for years to come.

In the book, Mr. Cohn takes a good look at this most contentious legislation. This is not a liberal look at the ACA, but a timeline of all the wheeling, dealing, compromises and political maneuvering done by both parties to pass, and later get rid of this legislation.

Meticulously researched while still written in an accessible narrative, The Ten Year War chronicles the history of the Affordable Care Act - and more broadly health policy in the US over time. Even having lived through it as an interested and careful observer (working in health policy though not in politics), I learned so much. Lots of good lessons learned for progressive policy making doing forward as well.

Thanks to St Martins Press and NetGalley for the early copy in exchange for an honest review.

Jonathan Cohn is one of our best policy journalists. His book Sick, published in 2008, was popular with a broad audience and helped advance a consensus among Americans that healthcare reform was needed. In The Ten Year War, Cohn follows up on that book’s depiction of the symptoms of policy failure with a history of how the US addressed and attempted to remedy those failures. While Cohn provides a brief history of previous attempts at universal coverage from the New Deal through to Medicare and then to Clintoncare, the title of his book refers to the fight to enact the Affordable Care Act and the subsequent battles to preserve it. The book is accessible and plainly written, helping to distill complex history and policy for the reader, and I imagine will be well received as a synthetization of the most recent ten-year fight for increased access and affordability in healthcare.

In an era of fast news, click bait, and Twitter outrages over issues that change from moment to moment, it is hard to remember the specifics of the healthcare debate from as recently as 2018. For this purpose, I appreciated Cohn’s straight retelling of the fight for Obamacare. In 2021, many forget how difficult it was to pass the ACA in 2010 and even harder to remember that in many cases Democrats were not just negotiating with Republicans but with conservative Democrats to pass something that accomplished twin goals of increasing healthcare coverage and decreasing cost. Cohn reasons that the ACA is the best thing we could have gotten in 2010, and it remains an important accomplishment.

While most of the book aims to remind you of the trajectory of the ACA, the most interesting parts are in Cohn’s detailed reporting of actions taken by staffers and policymakers who are not well known in the broad strokes tiktok of healthcare reform. These individuals include Jeanne Lambrew and Nancy-Anne Deparle, who worked largely behind the scenes in unglamorous roles, but bear responsibility for many of the law’s success in conception and action. Cohn aptly points out that many of the actors who were most deeply invested in healthcare policy were women, which recontextualizes the ACA’s history where most of the names remembered are those of the men. This is of course with the exception to Nancy Pelosi, who deserves an incredible amount of credit for stewarding her chamber through the fight for reform.

The book’s coda presents a way forward for healthcare politics where things are even more immovable with a conservative party more concerned with communications than legislation. That way forward is learning from this history. The Ten Year War will appeal to readers who already follow Cohn and are interested in healthcare policy. It has broader appeal in its plain use of language and clear explanation of complicated policy. Cohn mercifully doesn’t require “pre-reading” for his audience! Overall, The Ten Year War does an excellent job making the book accessible for all readers.

I am hoping ObamaCare is here to stay. This book details all the troubles in passing the law and all the issues with keeping the Republicans from getting rid of it.