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The 2010 Patient Protection and Affordable Care Act (ACA) is introducing extensive changes to the US health care system, including new requirements around the provision of health insurance coverage for employers. There is much debate as to how employers will respond to those new requirements, with estimates of the likely impacts on employer-sponsored coverage varying widely. This chapter capitalizes on the real-world experience under health reform in Massachusetts, the template for the ACA, to examine how employers responded to that state’s 2006 health-reform initiative. Although details of the employer requirements in the national legislation differ somewhat from those in the Massachusetts law, the broad tenets of the two initiatives are similar and so the response by employers in Massachusetts provides objective evidence of the potential response by employers to the national legislation.

The political analysis that resulted in the adoption of the universal right to health in the 1988 Federal Constitution and the intellectual foundations of the health sector reform are examined in this chapter. In connection with the democratic transition of the 1980s, it highlights the role of political argumentation by the epistemic community of experts in the health field as central to the universalist health sector reform. The basis for argumentation in favour of the health sector reform was produced by researchers at public universities and research institutes, who challenged the idea of subordinating the reform to the social security conception in favour of the proposal for universalization supported by general taxation. This community's analytical output concentrated on deconstructing the government's medical care policy at a time when the constitutional drafting assembly was calling for institutional arguments to justify the health sector reform project, and thus ensured the reform's approval.

The chapter begins with a review of the efforts to reform health care in ways that would assure health care for all Americans, beginning with Progressive Era reforms in the early 1900’s through the William Clinton administration’s ill-fated Health Security Act in the early 1990’s. After delving into the less ambitious reforms of late 1900’s aimed at cost-containment and incremental expansions of health insurance coverage for low-income children, the chapter examines the devolution of the employment-based insurance for working families was pivotal to the economic and political context of the Affordable Care Act (ACA) of 2009 –the first federal legislation in U.S. history to advance universal health insurance for all American citizens as its central goal. The chapter concludes with a prognosis for the successful implementation of the ACA, as well as its long term prospects.

The introduction outlines the book’s central argument: that writers throughout the nineteenth century took health reformers’ ideas about the human body as opportunities to imagine ways of being in the world that are individually and socially ameliorative. It proposes the term “bioplasticity” as a term to describe reformers’ shared belief that the human body is plastic and amenable to change, whether for good or for ill. It provides an overview of the book’s methodology and describes the historical and cultural contexts of antebellum reform culture. It discusses the ways that sex, gender, and race were mediated by this culture.

Chapter five charts how and why the medical profession developed and popularized the view that heavy habitual drinking constitutes an incurable physiological disease. In public lectures, journals, and speeches, physicians detailed the catalogue of destruction wreaked by alcohol, publicizing a new pathology of intemperance. Through vivid description and illustration, physicians asserted that the drunkard’s compulsion to drink derived from a diseased stomach. While heightening public fear, however, physicians had little inclination to attempt to develop a cure for the condition. Promising therapies emerged in the 1820s which physicians actively discouraged people from using. By mid century, finally spurred on by patient demand, physicians experimented with treating inebriates in hospitals and asylums, but their efforts remained scattered and experimental. This chapter argues that by heightening public fear, but failing to develop therapies, physicians encouraged the popularity of the Washingtonians, who promised to cure drunkards. As Washingtonians exerted an ever-greater influence on popular culture, sensational accounts of delirium tremens proliferated. The medical impulse to pathologize habitual drinking thus led to a popular lurid fascination with the drunkard’s struggle with the cravings for drink.