The future of Obamacare.

n engl j med 367;23 nejm.org december 6, 2012 2165 it passed Congress without a sin­ gle Republican vote, and the GOP subsequently mounted legal and legislative challenges to Obama­ care, vowing to repeal and re­ place it. The Supreme Court decision in June 2012 upholding the ACA’s constitutionality dealt a serious blow to the law’s opponents. Now, in the aftermath of the 2012 elections, with President Barack Obama reelected and Democrats maintaining majority control of the Senate, Republicans lack a viable option for overturning the law through legislative or execu­ tive action. There will be no Re­ publican in the White House be­ fore 2017 at the earliest, and by then the ACA’s core provisions will have been in effect for 3 years (see timeline).1 It’s difficult to take benefits away once they’re in place — one reason that many Republicans saw the 2012 elec­ tions as their last chance to de­ rail Obamacare. Republicans can still target politically vulnerable provisions of the law — such as the Medicare Independent Payment Advisory Board. House Republicans may use their leverage in budget nego­ tiations to try to extract conces­ sions, such as postponing select­ ed provisions, cutting funding for implementation, and granting states more discretion. But these tactics of delay, defunding, and devolution ultimately cannot stop the ACA from moving forward. As Speaker of the House John Boehner (R­OH) conceded after the election, the ACA is “the law of the land.” Now that the threat of repeal has faded, what is the future of Obamacare? What challenges and conflicts lie ahead on the long road of implementation for health care reform? In the short term, the spot­ light is on the states. States are grappling with their role in estab­ lishing health insurance exchang­ es — regulated marketplaces where the uninsured and small businesses will shop for coverage. Initially, 16 states and the District of Columbia will operate their own exchanges. Another 15 have, to date, refused to create ex­ The Future of Obamacare