Neither Republicans nor Democrats have spent much time, at least not in public, discussing changes to the Affordable Care Act (ACA) that could refine or improve the legislation. Republicans have mostly focused on strategies to repeal the ACA, which, even with their control of the House and Senate, appears highly unlikely because they could not muster the 67 votes needed to override a presidential veto. Democrats, while privately acknowledging there are changes that could improve the legislation, have publicly devoted most of their energies to defending the ACA.

The history of complex legislation is that it usually produces follow-on legislation that refines or modifies the original legislation because of unintended consequences or unanticipated political pushback following the bill’s implementation. Several rounds of such legislation followed the Balanced Budget Act, for example.^1,2 Although it could be argued that major portions of the ACA were not implemented until 2014 so that not having introduced modifying or corrective legislation by mid-2015 is not unusual, it is clear that the acrimonious and partisan passage of the legislation has made corrective legislation in the near term highly unlikely, although the overwhelming passage of the sustainable growth rate reform by both houses of congress in the spring suggests that corrective legislation is not impossible.³ However, sustainable growth rate reform appears to be a special case, reflecting the strong interest of Congress to dispose of what had become a festering annoyance, and was able to happen only because Congress ignored the most contentious aspect of the legislation—funding its cost. The only comparable situation would have been the need to replace the current system of subsidies in the federal exchanges had the Supreme Court ruled against the government. Even that would have been as likely to result in a bill that continued the current system of subsidies until after the 2016 election.