President Barack Obama's re-election cements his signature law -- Obamacare -- in American history.
The Affordable Care Act of 2010 first survived a U.S. Supreme Court challenge and on Tuesday avoided Mitt Romney's vow to begin repealing it "on day one" of his presidency.
Now, "this is the law of the land," Kansas Insurance Commissioner Sandy Praeger said. "I don't see it going away."
The survival of the law green lights the most monumental change in how health care will be delivered since Medicare and Medicaid were created in the 1960s. In extending coverage to about 30 million uninsured, the United States will join most other developed nations in the world who provide health care coverage to all.
Supporters say reform, to phase in by 2014, is overdue.
"We finally have a method for everyone to get their health care services in a timely fashion and have some method for paying for it," Praeger said.
Specifically, the law guarantees that citizens have access to health care coverage at group rates if they're not already covered by company or government plans. It requires that insurers cover pre-existing conditions and expands Medicaid.
Through the so-called individual mandate -- upheld by the U.S. Supreme Court -- people not already covered will have to buy insurance or pay a penalty. Lower-income people will get a subsidy to help them buy insurance offered on new online exchanges.
Although designed to curb cost increases, whether it will make health care more affordable is uncertain. Legal challenges remain. Countless regulations still need to be published, primarily by the U.S. Department of Health and Human Services. And states can still stymie some steps.
Missouri and Kansas are among dozens of states with legislatures or governors that don't intend to meet the deadline to establish state-based insurance exchanges by 2014.
The state exchanges were conceived as online marketplaces for consumers to compare insurance plans and costs and buy coverage. In states such as Missouri and Kansas, the law provides for a yet-to-be-explained federal exchange to be offered as an alternative. Most observers expect that guidelines for the exchanges will be released within weeks.
On a ballot question Tuesday, Missouri voters by a huge margin said the power to create the state's exchange belongs to the legislature and the voters, not the governor, eliminating the chance that Democratic Gov. Jay Nixon might authorize the state's exchange by governor's order.
Kansas Gov. Sam Brownback has rejected Obamacare on all fronts. Praeger said her state insurance office is unsure what options Kansas has to partner with a federal exchange.
Despite Obamacare being a flash point for public opinion, health care wasn't a top presidential campaign issue. It went on the back burner partly because Romney couldn't campaign hard against a coverage policy that he implemented in Massachusetts as governor.
In national exit polling Tuesday, 49 percent of voters said all or part of Obamacare should be repealed, and 44 percent said the law should be kept or expanded.
Most surveys, pre- and post-election, showed Americans' distaste for health reform when asked broadly about Obamacare. But in more detailed surveys, most respondents liked specific parts of the law, such as coverage for pre-existing conditions and the ability to keep dependents up to age 26 on parents' policies.
Despite confusion over regulations and implementation, supporters of the act celebrated Wednesday.
Ethan Rome, executive director of Health Care for America Now, said Obamacare is "here to stay" and that's "huge news for the 129 million Americans with pre-existing conditions ... who won't face insurance company discrimination anymore."
But meeting the law's requirements puts insurers, such as Blue Cross and Blue Shield of Kansas City, under the gun.
"The administration has held off issuing a whole host of regulations that will now hit the insurance industry in an onslaught," said David Gentile, chief executive of the organization in Kansas City.
Insurers must deal with a host of internal compliance details. For instance, they need clarity on what "essential health benefits" the law requires them to cover.
Even if those details are published before the first of the year, "we have a very short window to be educational in the marketplace" -- about 10 months -- to design plans and educate consumers about their insurance options for 2014, Gentile said.
Tracy Watts, national health care reform leader for Mercer, noted that the law requires employers in 2014 to meet detailed reporting and disclosure requirements to the federal government about their employees and their access to "minimum benefits at an affordable cost."
"Corporate IT departments need months of lead time to get something done with this kind of database," Watts said. "All of a sudden, employers won't have much lead time."
Some employers already are trying to decide what they'll do in 2014. Brian Finucane, an employment law attorney at Fisher and Phillips in Kansas City, said one of the law firm's first calls Wednesday was from an employer with about 1,000 workers on payroll.
"He wants to consider whether to pay $10 million in health insurance for his employees or pay the $2 million penalty," Finucane said, referring to a 2014 clause affecting workplaces with 50 or more employees if the employer opts out of offering insurance.
The possibility of legal challenges to the act also remains.
Liberty University, which filed suit in 2010 to block enforcement of the law, was denied consideration of its case by an appellate court after the Supreme Court decision on mandates. Liberty has petitioned the Supreme Court for a rehearing on the grounds that the case considered by the high court didn't deal with all of Liberty's objections to the law.
If the high court remands the Liberty case to be reconsidered, that could expose several aspects of the law to a long re-litigation process.
"You may say, let's move on. The Supreme Court OK'd it. Obama won. Advantage Democrats," Finucane said. "But the political fight is far from over. This is a story to be continued."