As world events have come to dominate the news in America, health reform appears to have slipped from the front page. But in the backrooms of Capitol Hill and the White House, discussions are as furious as ever. On Christmas Eve, the Senate passed a healthcare reform bill, just as the House of Representatives had done in August. The two bills are similar but not identical. The behind the scenes task is to reach a set of compromises and produce a single bill that the President can sign into law.

Earlier controversies have now been resolved. A mandate requiring individuals to purchase insurance or face a fine looks likely but the public plan idea is dead. The uninsured will choose from a set of competing private plans in a health insurance exchange, with no public option to shape or distort the market, depending on your view. The most comprehensive plans, or Cadillac plans as they have come to be known, will be subject to a special tax. Surprisingly, it is not the wealthy who stand to lose from this provision but unionised workers such as state employees, teachers and healthcare professionals. While not successful in scrapping the provision entirely, the unions have managed to negotiate a delay to the start of this new tax until 2018. Cover for abortion remains contentious, as it does all too often in American politics. Under current proposals, federally funded subsidies would be available to help the uninsured by coverage. It is possible that some of the uninsured will buy health plans that include abortion services using these subsidies. The disagreement is over the extent to which is violates an existing prohibition on the use of federal funds for abortions.

Although these controversies have pushed health reform into 2010, there is still confidence in Washington that some form of legislation will be passed. With that in mind, many within the Obama Administration have turned their attention to implementation. Many of the programs that need to be put in place have little precedent and are not well defined in legislation, for instance the health insurance exchange and the proposed government-run long term care insurance program. While many provisions do not start immediately, three years is not long to design, regulate and implement a program from scratch, while keeping existing initiatives ticking over. It will be tempting to turn our attention away once the final vote is cast in Congress, assuming the hard work is over. On the contrary, many of the decisions that will affect access to healthcare, its quality and cost will not be made by the politicians currently negotiating behind closed doors but by the civil servants who will take up the challenge once the legislation is passed.

Vidhya Alakeson is a former Harkness Fellow in Healthcare Policy based in Washington DC.