Administration officials say their most immediate concern will be implementing the "early deliverables" — the parts of the new law that go into effect almost right away. Among them are tax credits to help an estimated 4 million small businesses provide coverage for their workers, assistance for people who have pre-existing conditions, a provision allowing young adults up to age 26 to stay on their parents' policies and a $250 rebate for seniors whose initial Medicare drug benefits have run out.
Here's another challenge: filling key posts in the Executive Branch that remain empty more than 14 months after Obama was inaugurated. After all, there will be thousands and thousands of new regulations to be written and administered. But no one has yet been named to head the Centers for Medicare and Medicaid Services, the huge agency that runs those two programs. And Senate Republicans have held up the nomination of Columbia University professor Sherry Glied for the important post of Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services. Congressman George Miller, chairman of the House Committee on Education and Labor, grouses that the Administration "is going to have to be more aggressive. They have not been aggressive enough on the appointments process."
Over the longer term, as more and more parts of the new law go into effect, officials on both ends of Pennsylvania Avenue promise they will be watching closely to see whether it is working as intended. "There's a lot of money that's going to be spent in accomplishing these goals," says House Energy and Commerce Committee chairman Henry Waxman. "We've got to be mindful of that."
Among the questions they will be asking: Are the exchanges working? Are the billions that are going into health-information technology — like electronic health records — paying off as promised? Is it a good thing or a bad thing if businesses decide to start sending their employees into the government-subsidized exchanges rather than providing coverage themselves? And are the subsidies the government provides adequate for the middle-income people who are required to buy insurance? "The worst thing would be to end up mandating coverage people can't afford," says Andy Stern, president of the Service Employees International Union, which represents many of the nation's health care workers.
Vigilance, of course, is a good thing. But as the forces of reform take hold, there is also the possibility that Congress will be tempted to meddle too much — intervening, for instance, to take care of hospitals in members' home districts or to insulate powerful and moneyed special-interest groups like drugmakers. As Stern puts it, "The question is whether Congress can restrain itself and let the market work, or whether they are going to be distorting the system day by day."
So if there is a victory lap to be taken now, it had better be a short one. As Obama said shortly after signing the bill, "For those of us who fought so hard for these reforms and believe in them so deeply, I have to remind you our job is not finished." Indeed, it has only just begun.