President Barack Obama's health care reform law survived a couple of brutal battles this year. In the first major match of 2012, we watched 27 states try to kill the Affordable Care Act in the U.S. Supreme Court, claiming that it violated constitutional law. The punch line, however, was delivered in a 5-4 decision that left most of the act standing as the supreme law of the land.

Bruised but not broken, the health care act then began slouching toward November, through blistering bipartisan bickering, facing peril of extinction should Obama lose the election. Indeed, Republican candidate Mitt Romney had promised to begin repealing the act on his very first day in office.

But with Obama's re-election last week, the embattled health care act was again resuscitated and restored to health. And because the act was such an integral feature of Obama's campaign platform, American voters provided much of the saving life support for Obamacare.

As such, Obamacare now claims considerable public approval as well as established majority support in both Congress and the Supreme Court. Clearly, it's time to recognize the health care act as a legitimate reality that is here to stay. Additional expenditures of time, money, or political capital trying to deny its existence or make it disappear are plainly sad, tedious, and wasteful endeavors.


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Indeed, an invigorated Obamacare left the ICU on Nov. 6 and resumed its muscular sprint into our future. If it ultimately reaches its goal, as many as 30 million previously uninsured Americans will receive health care coverage by 2014. And, in my view, that's a most honorable achievement.

Still, the health care act faces formidable logistical and political hurdles in its path. All along, one of the greatest obstacles has been its "identity problem." Not only was the act's image repeatedly distorted for political expediency, but its body of law remained poorly described and explained to the public.

That made it difficult for many to recognize the act for what it actually was, and, therefore, to formulate confident opinions about its problems and merits.

For example, during recent campaign coverage, some voters expressed hesitation about endorsing Obama because they thought it would newly invite Obamacare and Big Government into their lives. They did not seem to recognize that the health care act had been solidly in their midst -- for two full years -- and that most Americans had been pleased by what Obamacare had brought.

In 2010, young adults were allowed to remain covered by their parents' health plan until they turned 26 years of age. In 2011, the act had extended prescription drug discounts and free preventive services for Medicare recipients, and it required insurance companies to spend the vast majority of collected premiums on actual health care benefits and quality improvement.

New health care rules also prohibited insurance companies from denying coverage to children due to pre-existing conditions, and from imposing lifetime dollar limits on coverage.

Yes, these and other changes were part and parcel of Obamacare, brought to us courtesy of Big Government, the same Big Government that delivered FEMA to the grateful citizens of New Jersey and New York in the recent wake of Sandy's devastation.

Currently, the health care act is about midway in its track, but heading into a more challenging last few years of its fuller implementation. Some additional consumer protections should easily fall into place by 2014 -- foremost among them, laws that prohibit insurance companies from imposing annual dollar limits on coverage and denying coverage to adults with pre-existing conditions.

The act is likely to encounter its greatest obstacle in quest of its most critical mission: to expand insurance coverage to about 30 million currently uninsured Americans. The obstacle emerges because the goal of expanded coverage primarily relies upon three passionately contested strategies.

The first beleaguered strategy concerns the act's individual insurance mandate, which requires nearly all Americans to own or purchase insurance by 2014 or pay a tax. While declared constitutional by the Supreme Court, that mandate still bothers many Americans who feel unduly coerced by government to purchase a commodity they do not want.

The second such strategy depends upon the creation of state-based health insurance "exchanges" by 2014 that are supposed to provide competitive marketplaces where people without employer coverage can shop for affordable plans. But states were required to notify federal regulators by Nov. 16 whether they intended to operate a state-based exchange or a partnership exchange with the federal government. Still, as recently as late September, the majority of states had yet to submit any plan.

Finally, the third contested strategy relies heavily upon a robust expansion of the Medicaid insurance program (known as Medi-Cal in California). Currently, this government program covers about 62 million low-income or disabled Americans. In 2014, the health care act expands Medicaid eligibility to Americans earning less than 133 percent of the poverty level (that means annual incomes of about $14,000 for individuals or $29,000 for a family of four). That expansion could add 17 million more people to the Medicaid program. Indeed, the health care act's financial incentives for state participation are rather compelling: 100 percent federal funding for the first three years and 90 percent each year thereafter. And yet, serious concerns remain that Medicaid's low reimbursement rates to doctors will continue to limit patient access to medical care. Additionally, the act permits states to opt out of the expansion.

In the end, substantive questions remain as to how the health care act will be implemented over the next two years, and how it will weather bipartisan discussions on the sharp edge of our looming fiscal cliff. We are simply going to have to hang on.

Kate Scannell is a Bay Area physician and syndicated columnist; contact her at www.katescannellmd.com.