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With Some Big Questions Answered by the Election, What’s Next for the Health Care Law?

For months, we’ve debated about what might happen in the next few years with respect to health policy. With the results of yesterday’s election, we can start speaking with more specificity. The big questions have centered on 2 factors: who might win the presidency and which party might hold the Senate.

Both of those have been decided, and to the surprise of some, both have been resolved in favor of the Democratic party. And that means that both have been decided in favor of the Affordable Care Act (ACA). The survival of the law, passed just a few years ago, has remained tenuous. Essentially every Republican candidate who ran for office pledged its repeal. Poll after poll seemed to show that people didn’t like the law or that physicians were dead set against it. But it’s hard to see the results of this election and assume some sort of mandate against health care reform.

Repeal of Obamacare was always a tough climb. It was possible that a Republican House and a Republican Senate could use reconciliation to overcome a Democratic filibuster and pass a law repealing many of the provisions of the law. It’s possible that a President Romney could have signed that law. But with a Democratic Senate, that’s not going to happen.

Still, it was possible that a President Romney could pass executive orders to strangle the implementation of the law. Even with no chance of full-out repeal, he could have done quite a bit to slow or hinder its enactment. But now even that path is gone with President Obama’s reelection.

Now, the state insurance exchanges mandated by the law will go into effect in 2014. The Medicaid expansion will occur. Just weeks ago, economist and fellow JAMA Forum contributor Austin Frakt and I wrote a Viewpoint for JAMA where we compared the health care policies of the 2 campaigns. Now, one is going into effect.

This is what will happen:

Adapted from JAMA. 2012;308(16):1-2. Sources: CBO (July 24, 2012); 2009, 2010, and 2012 Long Term Budget Outlook, CBO (June 2009, 2010, and 2012); and Updated Budget Projections, Fiscal Years 2012 to 2022, CBO (March 2012).

As you can see, government spending on private insurance is going to increase. This includes subsidies for many people who will begin to buy insurance through the exchanges. Medicare spending, contrary to what you might have heard, is also going to increase. That’s because no one actually suggested flat-out reducing spending on the program. President Obama has just been proposing slowing future growth in spending, so that it’s less than what might have otherwise occurred.

But let’s be clear: there are still some factors beyond the control of President Obama and the Democrats. State governments have much to do with its local implementation, and the political stance of many such localities differ greatly from the President’s. Moreover, although the ACA calls for a massive expansion of Medicaid to cover some 16 million Americans who previously lacked insurance, the implementation of that expansion is far from assured. Over the summer, the Supreme Court ruled that the expansion is optional, and many states have equivocated and pledged not to do so.

I’ve long held that I believe few states will follow through with this threat. With the federal government picking up the vast majority of the cost of the expansion, there’s little downside in the short-term for states that accept the policy. There’s also a ton of upside—millions of people receiving insurance who previously lacked it. I still maintain that it will be difficult for governors to tell their constituents that they are refusing the federal government’s offer and leaving people uninsured for a political principle.

But it’s important to place this in context. In 2014, the ACA fully kicks in, and when that happens, it will be nearly impossible to dismantle it. Since its passage, the law has faced any number of potential turning points. It could have been trashed when the Democrats lost their 60th vote in the Senate. It could have been rendered unconstitutional by the Supreme Court. It could have been repealed through a loss in this election.

None of those things happened. For all the talk about its fragility and lack of support, the law has held. When Medicare was passed, it was decried as “socialism” and the “end of freedom.” Today, it’s as American as apple pie. It’s likely that decades from now, Obamacare will be viewed in the same way.

That’s not to say the law is perfect. There are any number of legitimate complaints against it. Health care is still incredibly expensive, and it’s unclear that the ACA goes far enough to contain costs. The quality of care in the United States is often suboptimal, and it’s unclear that the ACA does enough to make that better. And despite the ACA’s passage, millions of Americans will still be without insurance.

We can do better. We must do better. But now perhaps the discussion can turn away from talk of repealing and move towards improving the ACA, to get a better health care system for all Americans.

About the author: Aaron E. Carroll, MD, MS, is a health services researcher and the Vice Chair for Health Policy and Outcomes Research in the Department of Pediatrics at Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.
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