Pitched battles over aspects of the law will continue, but the fundamental reality is that stakeholders are fully engaged, and implementation will move ahead.
The drive to implement the Affordable Care Act (ACA) now appears to be irreversible. Efforts will persist to derail it through legal challenges, or through bills that pass the Republican-controlled House of Representatives and then die in the Senate. This pattern of sustained but ineffectual opposition is not unusual in American social policy. After its enactment in 1935, Social Security was also politically stalked, but it rarely faced a serious challenge after it became fully operational following World War II.
More consequential for the future of health reform are the new arenas and forms of politics. As the highly public jousting of partisans in the legislative and judicial arenas gradually recedes, states and the federal administrative processes will become the focal point for stakeholders and beneficiaries. The ACA is now out of intensive care. It will face a new set of challenges in the rough-and-tumble bargaining of American politics, but odds are that the patient will now survive—and thrive.