One Battle in a Long War

In the fight for universal health insurance, affirmation of the Affordable Care Act (A.C.A.) is a small victory that prevented a major rout. But the next big battle is already upon us: the presidential and Congressional elections in November.

The act might reduce the number of uninsured by 30 million (from the about 50 million now). My gut feeling is that it may be closer to 25 million, as Congress is likely to trim the subsidies for families above 300 percent of the federal poverty level.

Depending on the fall election, significant portions of the act -- especially the subsidies for low- income people -- might be severely clipped.

The A.C.A. has provisions for the development of a number of tools that could be used to constrain the future growth of health spending -- among them bundled payments in place of the inflationary fee-for-service payment, clinically integrated health care, greater transparency of the prices and quality of individual providers. But the act itself would not in this decade reduce total national health spending. On the contrary, by itself it will increase spending slightly.

And, of course, if 30 million additional people with health insurance demand more health care, it will put pressure on an already tight supply of physicians -- especially primary-care physicians.

But depending upon the outcome of the fall election, significant portions of the act -- especially the subsidies for health insurance of low- income people -- might be severely clipped or even eliminated. I believe that could be done through a budget reconciliation that cannot be filibustered in the Senate.

So, after today's euphoria and, on the other side, despair, the battle goes on.

A few years ago I wrote a piece in Health Affairs entitled "Is there Hope for the Uninsured?" I answered "No." After today I would modify it to "A little!"   link 
Kaiser Health Tracking Poll link

Uwe E. Reinhardt is a professor of political economy, economics and public affairs at Princeton University. Updated June 29, 2012, 12:36 AM