The Affordable Care Act turns 12 on Wednesday, and the tumultuous debate over its existence seems to be over.

Polls consistently find majorities of American approve of the law. Conservatives have run out of major constitutional challenges . Repeal is not on the Republican agenda anymore, and a few weeks ago, when Sen. Ron Johnson (R-Wis.) suggested off-handedly that maybe Republicans should take it up again, he promptly walked back the statement with a news release clarifying that he didnt really mean it.

But Year 13 could be a tumultuous one.

Officials in Washington and in state capitals face a series of key decisions about the future of Obamacare, and, depending on what they decide, literally millions of Americans could gain or lose health insurance although not too many people outside of political and policy circles seem to have noticed.

Heres whats at stake.

Making ACA Improvements Permanent

The American Rescue Plan, the COVID-19 relief bill that Democrats passed and President Joe Biden signed in March 2021, ramped up the financial assistance available to people buying coverage on their own through HealthCare.gov or state-run exchanges such as Covered California.

That boost made a big difference, reducing premiums by hundreds or even thousands of dollars a year. But the extra financial help ends at the end of 2022, when premiums will go back up for millions of insurance buyers unless Congress makes the increase permanent or at least extends it for a few more years.