In the aftermath of the Supreme Court decision largely upholding the constitutionality of the Affordable Care Act, many stakeholders have renewed their commitment to health care reform. In fact, a new political economy of health care has emerged that is characterized by three dynamics. One is the “log-rolling” dynamic of distributive politics, as evident in mutually supportive efforts for maintenance and expansion of subsidies and other opportunities to advance the interests of stakeholders. A second is the cut-throat zero-sum politics of interest-group conflict, as evident in the intense competition among stakeholders for limited resources and authority. The third dynamic is the result of the emotional and ideological conflicts of resource redistribution. These new dynamics may make repeal of reform more daunting than expected.