In 1912, Theodore Roosevelt, the 26th president of the United States (1901-9), formed the short lived Progressive Party, which campaigned on a promise of national health insurance. “What Germany has done in the way of old age pensions or insurance,” he said “should be studied by us, and the system adapted to our uses.”1 So began the story of successive American presidents trying and failing to achieve comprehensive health reform. On Sunday 21 March 2010, at 10.45 pm in Washington, DC, after a year of rising and falling political fortunes, Barack Obama, the 44th president, brought the story to an end with the passage of a bill that achieves near universal health insurance. The bill will be his legacy.

Three policy imperatives shaped the landmark legislation. The first was to expand health insurance coverage. The US is the only major industrialised nation that fails to guarantee coverage for all its citizens.2 More than 46 million Americans are uninsured, and a recent study estimated that about 45 000 deaths a year are associated with lack of insurance.3 4 The second was to end the unfair practices of the private health insurance industry, such as denying coverage to anyone with a “pre-existing medical condition” or rescinding coverage when a patient gets ill. The third was to curb the spiralling costs of health care, which were threatening to explode the federal budget.

Tackling these policy imperatives was a huge …