WASHINGTON – The country finally has an opportunity to change the subject on health care, after the Supreme Court again upheld President Barack Obama's law.
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There's no shortage of pressing issues, including prescription drug prices, high insurance deductibles and long-term care.
But moving on will take time, partly because many Republicans want another chance to repeal the Affordable Care Act if they win the White House and both chambers of Congress next year.
Also, it's difficult to start new conversations when political divisions are so raw, and there's a big disconnect between what people perceive as problems and the priorities of policymakers, business and the health care industry.
Democrats say a change in focus is long overdue.
"I do think the energy has already shifted," said Neera Tanden, president of the Center for American Progress, a think tank often aligned with the White House. "It would be great if the health care conversation moves to where people are, not relitigating these insurance issues."
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Wishful thinking, say Republicans.
"The politics of this has gotten so unpleasant that we're locked into 'repeal-and-replace' for the next year and a half," said lobbyist Tom Scully, who ran Medicare in President George W. Bush's administration. "It may not be great for America, but that's the reality."
Scully says Republicans may be able to make substantial changes but not repeal Obama's law entirely.
What would a different health care conversation sound like? Some possibilities:
PRESCRIPTION DRUG PRICES
Nearly three-quarters of the general public see prescription drug costs as unreasonable, according to a recent Kaiser Family Foundation survey. That concern seems to be driven by new breakthrough drugs that can cost $100,000 a year and even more. Last year it was Sovaldi, a cure for liver-wasting hepatitis C infection. Next it could be skin cancer drugs in the approval pipeline.
Economist Len Nichols of George Mason University in Virginia says the cost of new medications is "unsustainable," but government price controls could stifle innovation.
Most patients are not exposed to those excruciating cost pressures because the vast majority of prescriptions are for lower-priced generic drugs. Overall, only 1 in 5 people taking prescription drugs say it is difficult to afford their own medications, the same survey found.
HIGH INSURANCE COSTS
The value of a health insurance card is being eroded as employers and insurers impose higher deductibles, copayments and other cost-sharing on top of premiums.
"When people ask me what is the No. 1 change I want to make in the Affordable Care Act, my answer is that it's not affordable enough," said John McDonough, a former Democratic Senate aide who helped steer the health law to passage. "Moving forward, one of the challenges is how we're going to address this new world of cost sharing."
GETTING EVERYONE COVERED
When the health care law passed, a little more than 80 percent of people under 65 — the age to qualify for Medicare — had health insurance. That share is now up to around 90 percent, largely the result of the law.
Yet covering the remaining uninsured will be a challenge. Much depends on some 20 states — mainly GOP-led — that have not accepted the health care law's Medicaid expansion. The ruling may budge a couple, but probably not Texas, the biggest prize.
"The people who are going without coverage in states whose leaders are denying them a chance to get Medicaid are pawns in a political game," said former California Democratic Rep. Henry Waxman, one of the main authors of the health law.
Economist Gail Wilensky, an adviser to Republicans, says the patchwork system for caring for frail older people and the disabled "is an issue that isn't going away." She's involved with an informal discussion group that spans the political spectrum, looking for long-term care ideas that might find support. It could take years.
"I don't see any stomach for taking on these issues post-King v. Burwell," she said, referring to the name of the Supreme Court case decided this past week. "People are going to need time."
PAYING FOR QUALITY AND EFFICIENCY
Revamping the way hospitals and doctors are paid for their services is the top issue for employers, insurers and government programs such as Medicare and Medicaid. Everyone wants to get away from compensating providers on a piecemeal basis for the sheer volume of services. But defining what constitutes quality care turns out to be not so easy, and it's unclear whether the new approaches will produce significant savings.
Look for these changes to continue at full speed, aided by the spread of computerized medical records and increasingly sophisticated data analysis.
There could be a downside, says Rep. Rosa DeLauro, D-Conn. "You're getting hospitals merging, and they are becoming mega-operations," she said. "Small doctors' groups feel like they are just being swallowed up."
When all is said and done, the U.S. still spends too much for health care. After a lull the last few years, spending is expected to pick up again. The government has its fingers in practically every pot, with a jumble of laws and regulations that create conflicting incentives, said economist Eugene Steuerle of the Urban Institute, a nonpartisan public policy center.
"We've got multiple and largely uncoordinated subsidies and rules," said Steuerle. "On the cost side, what I see is more and more efforts to put budget constraints on the system."