Since 2010, the fate of the Patient Protection and Affordable Care Act (PPACA) has been uncertain. In June 2012, the Supreme Court upheld the ACA’s constitutionality, dealing a serious blow to Republican efforts to overturn the law through legislative or executive action. No Republican will be in the White House before 2017, and by then the ACA’s core provisions will have been in effect for 3 years. Once benefits are in place, they are difficult to eliminate. So, what is the future of Obamacare? What challenges and conflicts loom on the horizon for implementation for health care reform?
The focus is now on the states, which are determining their roles in creating health insurance exchanges, that is, regulated marketplaces where the uninsured and small businesses can shop for coverage. Initially, 16 states and the District of Columbia will operate their own exchanges. Fifteen others have refused to create exchanges, so the federal government will operate exchanges in those states. Seven states will join with the federal government to cosponsor an exchange, and the remaining 12 states still must decide what to do. Although opponents hope that subsidies for the uninsured to purchase insurance will not be available in federal exchanges, the administration argues that the law clearly intends to provide subsidies in both state and federal exchanges. Questions remain about whether exchanges will be ready for the first enrollment period in October 2013, how these new marketplaces, offering more choice and competition, will fare in states where one insurer dominates the insurance market, and whether exchanges expand over time. States must also decide whether to expand eligibility for their Medicaid programs, which is optional. The hospital industry could become a powerful advocate for states to accept additional federal Medicaid funds.
Obamacare emulates the successful formula that Massachusetts used to increase access to insurance, but it cannot copy the state’s political environment. Health care reform in Massachusetts had broad bipartisan support. Whether the ACA’s individual mandate will have the same impact in states whose citizens are less supportive of reform and whose political leaders oppose the law is unknown. Political challenges to increasing Americans’ support remain because more Americans disapprove than approve of the law. That division reflects partisan polarization, the contentious debate over the law’s enactment, and the legacy of “death panels” and other myths, which have not disappeared. Unlike Medicare and Social Security, Obamacare does not have a well-defined population of beneficiaries, and its benefits are diffuse. The ACA is a series of programs, regulations, subsidies, and mandates that fill gaps in the current patchwork insurance system. The most difficult long-term challenge will be cost control. Pressures to rein in the federal budget deficit will only strengthen the resolve to hold down spending under the ACA.
Even as repeal is unlikely, many important future political fights will shape the future of Obamacare. The outcome of struggles over insurance subsidies and benefits, costs and financing, Medicaid, and many other issues will determine whether the ACA is maintained, expanded, or undermined.