is reputed to have said that 'To understand the man you have to know what was happening in the world when he was twenty'. The Affordable Care Act (ACA) in the United States (US) is not a bad example of this dictum. The ACA can be seen to be the result of the very many lessons that were learned during and from the fights over Bill Clinton's health care proposals of 1992-1994. At the same time, the ACA reflects the steadily growing political and ideological polarization, lobbying, economic inequality and the complexity of public policy in the US since at least 1994 if not 1980. 1-3 On the Democratic side, leaders attributed Clinton's failure to pass the health care reform of the early 1990s to a lack of Democratic unity and the opposition of powerful interest groups such as the pharmaceutical and insurance industries. In response, by the time of the 2008 presidential elections, the differences between Democrats had reduced considerably and their plans became similar. That was deliberate. Democrats and allied thinkers had not just put in years of work to develop a consensus that the party and health care interest groups could stomach. They had also decided that any success depended on unity. 4 What Republicans learned is less studied, but is there for those who look. A party with no particular commitment to health care access or equality, its leaders learned from the Clinton debacle and subsequent 1994 Republican electoral success that fierce opposition to Democratic health care plans reaps rewards. Both applied their lessons to produce the ACA. Democrats unified to produce a device of remarkable complexity. The ACA carefully balanced interest groups in the health care sector and the party, but this came at considerable cost, as for beneficiaries it remained unclear whether the legislation could lead to any improvements in their situation. For example, the individual mandate requires people to have insurance. Health insurers consistently poll as some of the most disliked companies in the US, so even if people like to be insured, they are unlikely to appreciate policies that benefit health insurers. 5