The re-election of US President Barack ObamaBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7591 (Published 08 November 2012) Cite this as: BMJ 2012;345:e7591
- Robert Steinbrook, professor adjunct
Having survived constitutional and political challenges, the implementation of the Patient Protection and Affordable Care Act in the United States is secure. On 6 November 2012, Democratic President Barack Obama was elected to a second term, narrowly but clearly defeating Republican Mitt Romney. Romney’s vow to “repeal and replace” the healthcare reforms known as “Obamacare” was a key aspect of his campaign. With Obama’s victory, millions of people will gain health insurance over the next decade, either through the private market or the expansion of Medicaid, a joint federal-state insurance program for people with low income or certain disabilities. In addition, the structure of Medicare, the federal insurance program for elderly and disabled people, should be retained.
The US presidential election was very close; a shift of several hundred thousand votes (out of more than 118 million votes cast nationally) in a handful of battleground states—including Florida, Ohio, and Virginia—could have given Romney the 270 electoral votes needed for victory, and, possibly, the power to block various aspects of the Affordable Care Act. Obama, however, won the national vote and at least 303 electoral votes.
Despite billions of dollars spent on campaigning, the balance of power in the US government remains essentially the same. The Obama administration’s policies will go forward. There will be new senators and representatives, but the Democrats retained control of the Senate, with a slightly larger majority than before. The Republicans maintained a majority in the House of Representatives, but a slightly smaller one.
Enacted in 2010, the Affordable Care Act was a signature legislative achievement of Obama’s first term.1 In June 2012, the US Supreme Court ruled constitutional a salient feature of the act, known as the individual mandate.2 3 By 2014, the individual mandate requires most, but not all, Americans to buy a health insurance policy that provides at least minimum coverage or to pay a tax penalty to the federal government. The court scaled back another section of the act that broadened eligibility for Medicaid, thus creating uncertainty about how many states will participate in the expanded program. Otherwise, the Affordable Care Act remains intact, with many notable features taking effect in 2014. Insurers will no longer be allowed to deny coverage to people with pre-existing health conditions or to charge more to those with pre-existing conditions. Annual limits on insurance coverage will be eliminated. Online insurance marketplaces will be opened, and people with low or moderate incomes will be eligible for premium and cost sharing subsidies. In 2022, of 224 million non-elderly people in the US, as many as 90% will be insured.3
The election results notwithstanding, some will continue to object to the Affordable Care Act, perhaps mounting legal challenges to specific provisions. Republicans in the House of Representatives may push for delays, adjustments, or reduced funding, and raise questions about the act’s implementation. Such tactics, however, are unlikely to undermine the fundamental reforms.
With the elections over, the immediate question is whether Democrats and Republicans will put aside their partisan differences and reach budget, tax, and deficit reduction agreements that would halt the across the board federal spending cuts that are scheduled to take effect in January 2013. Time will tell if potential changes to the Affordable Care Act, Medicare, or other federal health programs will be part of the fiscal discussions. It should be possible for the politicians to reach meaningful agreements before the end of the year, and to avoid massive tax increases and spending cuts. But bipartisan accord in Congress has been elusive. If the reductions were to go forward, there would be profound consequences for federal health programs and agencies.
A question for the longer term is whether the US will finally get serious about controlling its very high level of healthcare spending. The Affordable Care Act includes some cost control measures, such as the creation of an Independent Payment Advisory Board that can propose reductions in Medicare spending in specified situations, subject to congressional review. But health insurance, not cost control, was the focus of the act. And even a board with limited authorities to make recommendations is controversial, because some see its very existence as tantamount to healthcare rationing.
Within 10 years, healthcare is projected to account for nearly 20% of the US economy. The Obama administration has not pushed for the types of cost containment approaches that work in other nations. “America continues to abide high prices and the staggering administrative costs imposed by our Byzantine insurance system,” the political scientist Jonathan Oberlander recently observed, noting that the nation has been “singularly unsuccessful in restraining health care spending.”4 Ultimately, fulfilling the promise of healthcare reform may depend not only on implementing the Affordable Care Act but also on continuing to extend insurance coverage and bringing healthcare spending under control.
Cite this as: BMJ 2012;345:e7591
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review. Commissioned; not externally peer reviewed.