New England Journal of Medicine

The Health Care War Isn’t Over

Health care reform advocates will and should celebrate their history-making legislative success. For many, the past year has been all health care all the time. Celebration should be limited, however. Major challenges lie ahead, and hard work remains to be done. Opponents will continue, and probably intensify, their opposition. They have promised legal challenges and are likely to seek repeal of all or part of the legislation. Moreover, formidable implementation hurdles must be surmounted if health care reform is to achieve its goals.

On the political front, Republicans unanimously opposed the final bill in both the House and the Senate. They have expressed outrage at the Democratic leadership’s decision to “ram through” reform using budget reconciliation to modify the Senate-passed bill sufficiently to make it acceptable to the House. The outrage is baseless, but the fury is real and will poison future debate. The first political testing ground will be the November 2010 midterm elections. Republicans have pledged to make the substance of the reform and the procedures used to enact it central to these elections. The Democratic majorities in both chambers of Congress are likely to be reduced, probably by even more than is usual for an off-year election. With 2010 gains under their belts, opponents will almost certainly continue and intensify attacks on the reform legislation during the 2012 presidential and congressional campaigns; they may well regain control of the Senate — 21 Democrats and 2 independents who vote with them, but only 10 Republicans, will be up for reelection — and could win the White House.

The reform legislation’s implementation schedule gives these political possibilities particular salience. Although many provisions of the bill will take effect immediately or soon after enactment, implementation of the bigticket items is deferred. The individual and employer mandates, the subsidies to make insurance affordable, the Medicaid expansion, and major insurance-market reforms will all start in 2014. And the tax on high-cost insurance plans goes into effect in 2018. Given the intensity of Republicans’ opposition to the substance and manner of passage of this reform, if the GOP regains the presidency and control of Congress in 2012, implementation could be substantially delayed or the law could be significantly modified or even repealed before its major elements have been implemented.