President Obama this week released his blueprint for a second term and it’s noteworthy that his goals for a second term don’t break any new ground on health care. Instead, his website lists 6 health care accomplishments that can be credited to the ACA. But what’s at stake for a second term is not just the continued existence of the ACA – with many experts predicting Romney’s pledge to repeal the ACA would be difficult to do – but whether and how it will get implemented.  With the often heated debate around what the ACA does and doesn’t do – and what opponents would do differently – it is easy to overlook the major milestone that was the bill’s passage.

It has often been said that every president since Harry Truman tried to tackle universal health care. And some along the way succeeded in enacting major policy changes: enactment of Medicare, Medicaid, and the Children’s Health Insurance Program. But President Obama’s signature domestic policy achievement tackled it all: those 3 programs, plus the cost and availability of the bucket of coverage most Americans have – private health insurance.

A second term for Obama means continuing on a path to all the ACA private insurance reforms that don’t take effect until 2014:

• an end to discrimination against people with pre-existing conditions;
• an end to annual limits on benefits;
• new rules on how insurers can set premiums, so that insurers can’t charge you more for a slew of factors, like being a woman or working at the wrong job;
• greater transparency and standardization, so consumers can make apples to apples comparisons of their plan choices;
• limits on how much consumers must pay out-of-pocket in a year; and
• new state-run health insurance marketplaces where consumers and small businesses can buy coverage – with a tax credit, for low and moderate income families and low-wage small businesses.

Governor Romney may not be able to pull off a full repeal of the ACA –despite his promise to do so – but a Romney Administration could slow down implementation of the ACA reforms that are slated to take effect in 2014 (for more on how the 2014 reforms are being addressed by state policymakers, check this out). For tens of millions of consumers who are denied coverage or charged more than they can pay, and for many more who have coverage that may cut off when they need it most, the ACA 2014 reforms hold the promise of a fairer, more reliable system of private health insurance – but only if they are implemented, as Obama promises to do with a second term. The bottom line is, reforming the private health insurance market so it provides more affordable and accessible coverage to every American is challenging and complex work.  The real question is, what alternative do we have?