Responding to cholera in post-earthquake Haiti.

3 nancially strapped and concerned about the cost of reform and its ability to meet their population’s needs. Maine, Florida, Iowa, and other states have already indicated that they will seek waivers for some insurance rules that could destabilize local insurance markets. A recent proposal by Senators Ron Wyden (D-OR) and Scott Brown (R-MA) would grant states additional f lexibility but falls short of giving them full authority to develop their own reform approaches. Since reform cannot be implemented without them, states could choose to take a more independent role even if Washington is slow to give it to them. Will the President’s health care reform look burdensome and unworkable 2 years from now? Reform is no longer a 2000-page bill sitting on the desk of a senator or representative. The executive branch has been issuing guidance and regulations that are beginning to fill holes in the legislation and will change the way the law works in practice. Much to the chagrin of the legislation’s most ardent supporters, Secretary of Health and Human Services Kathleen Sebelius has been granting waivers when the rules don’t work for everyone, albeit on a selective basis designed to avoid the worst political heat.3 Although such decisions will soften the impact of reform, they neither alter the shift toward greater government control nor slow the growth of health care spending. Despite the talk of repeal, Congress will not pass any major health legislation over the next 2 years, and the health sector and private employers will be hard at work preparing for 2014, when many ACA provisions take effect. That does not make health care reform a fait accompli. Absent a miracle, the country will still face crushing budget deficits when the next president takes office. A Republican president, backed by a Republican Congress, would be wise to delay enrollment in the health insurance exchanges, using the time and money to develop a more targeted plan that closes off open-ended subsidies for health insurance and gets the economic incentives right. A Democratic president would do the same thing out of necessity — but it would take longer.