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The Road Ahead for the Affordable Care Act
July 2, 2012 (10.1056/NEJMp1206845)
This is a nice discussion of the future of the ACA following the Supreme Court’s decision. Basically the Act’s future lies in the hands of the electorate. While there are many issues that deeply divide the country, the ACA will be one of the most divisive. What may be underappreciated by our non-US reader and many in the US is the comprehensive nature of the Act. If implemented, it will change the face of American medicine remarkably.“In January 2013, if Democrats hold the White House and Senate and regain control of the House, the ACA will be implemented mostly as constructed. If Republicans capture the White House and Senate and retain House control, the ACA will face major deconstruction early in 2013. Republican leaders will attempt to use Congress's budget-reconciliation authority to enact extensive repeal — and will need only 51 Senate votes, with no filibuster threat. If control of the White House and Congress is divided between the parties, then conflict over the law will persist. Thus, the November elections increasingly feel like a referendum on the ACA.
Unappreciated in this chaotic political environment is that the ACA is the first U.S. law to attempt comprehensive reform touching nearly every aspect of our health system. Even President Lyndon Johnson's achievement in establishing Medicare and Medicaid in 1965 was more narrowly focused. The law addresses far more than coverage, including health system quality and efficiency, prevention and wellness, the health care workforce, fraud and abuse, long-term care, biopharmaceuticals, elder abuse and neglect, the Indian Health Service, and other matters. In a less hostile political environment, congressional Democrats and Republicans would collaborate in assessing, modifying, and reconstructing many ACA elements, large and small — typical activities after the launch of any major law. And perhaps we will still get there, as the Supreme Court ruling begins to recede in the rearview mirror and the dust from the November elections settles.
For now, there are still many obstacles ahead.”