Implementing health care reform in US may still be difficult despite Obama win

BMJ 2012; 345 doi: (Published 08 November 2012) Cite this as: BMJ 2012;345:e7587
  1. Janice Hopkins Tanne
  1. 1New York

President Barack Obama said in his victory speech this week, after winning a second term in the White House, that the Affordable Care Act to expand health care to about 30 million uninsured people will go forward. The act was passed in March 2010 without Republican support.1

Although widespread health insurance is now a certainty for the United States, implementing the health reform act may not be smooth and easy. It will face lawsuits from groups that object to some of its provisions and objections from states that do not want to participate in parts of health reform, such as the creation of insurance exchanges and expansion of Medicaid.

During the election Republicans called health reform an example of big government intruding in people’s lives. Governor Mitt Romney had promised to repeal it if elected. Republicans might try to obstruct some of its provisions in the House of Representatives and in the states.

Democrats will continue to control the Senate, probably with a larger majority. Republicans will continue to control the House of Representatives. Thus the president might encounter the same gridlock as previously, although everyone seems to agree on the need to control the rising costs of healthcare. The health reform act provides funding for some experiments to slow the increase in costs.

Implementing the health reform act will involve actions by the states, and about 30 of them are Republican controlled.

By 1 January 2014, almost everyone will be required to purchase health insurance—the individual mandate—or face penalties that rise over time. People on lower incomes will be helped by subsidies. If people do not get health insurance through their jobs, the health reform act says that they can purchase it through exchanges, or marketplaces, in each state.

The exchanges will offer a selection of insurance plans, all of which must meet minimum standards. If the states do not set up exchanges—and several have said that they will not—the federal government can do so.

By 2014 insurance companies will not be able to deny insurance to people with pre-existing conditions.

Health insurance companies will benefit by having millions of new customers.

For people who have low incomes but are above the poverty line, the health reform act calls for providing them with health care through an expanded Medicaid program. At present Medicaid covers poor people and older people in nursing homes who have exhausted their savings.

Medicaid is a joint federal-state program. When the Supreme Court upheld the health reform act it said that states could not be forced to participate in expanded Medicaid.2 Several states have already indicated that they will not participate in the expansion even though the federal government would pay most of the cost. Those states could change in future if voters see the benefits in other states.

The Medicare insurance plan for older people faces rising costs and takes up a growing proportion of the federal budget. The Republicans had proposed a system in which older people would receive vouchers—a fixed sum of money—to use to buy Medicare or a health insurance plan. That proved unpopular, but the need to restrain Medicare’s increasing costs remains.


Cite this as: BMJ 2012;345:e7587