Although political rhetoric suggests major differences between the Presidential candidates on health policy, particularly over the Affordable Care Act and the future of Medicare, the political process does not readily permit adoption of campaign pledges. In this commentary, Robert Berenson reviews why the 2012 Election will largely continue on it current trajectory, no matter who wins the Presidency. That trajectory includes the systems evolution to Big Medicine, built on mega-hospital systems that absorb physician practices. Big Medicine so far has not been subject either to policy or political activity but could be a decisive influence on how health care is delivered into the future, for better or worse.