Under the Affordable Care Act, millions of Americans should be able to get… (Joe Raedle, Getty Images )
WASHINGTON — President Obama's victory all but assures that his landmark healthcare law and its guarantee of insurance coverage for nearly all Americans will be implemented, effectively putting an end to the Republican campaign to derail the law.
That outcome — which seemed almost unimaginable this spring when the Supreme Court considered whether the Affordable Care Act was constitutional — puts immediate pressure on many Republican state leaders who fought it. They must decide in days whether to implement it or have the federal government do it for them.
Tuesday's results also present Obama with a new set of challenges as he tries to fulfill the promise of his signature legislative achievement, the biggest expansion of the social safety net since Medicare and Medicaid were created in 1965.
Federal and state officials nationwide must create systems to handle millions of new insurance customers. Key will be setting up insurance marketplaces, known as exchanges, in every state by next October. (California has established one, but most states have not.)
Under the law, millions of Americans should be able to get health insurance for the first time starting in 2014. Millions more who don't get coverage through work should be able to buy a health plan that meets new basic standards.
"It's all over but the shouting," said Families USA Executive Director Ron Pollack, a consumer advocate and leading champion of the law. "What was very questionable at the start of the year has been settled. … The Affordable Care Act will be a permanent fixture of the American healthcare system."
But Obama will face renewed pressure to scale back the law as Congress tries to rein in federal budget deficits.
The act authorizes more than $1 trillion in new federal spending over the next decade. Although that is offset with new taxes and other spending cuts, critics say the law's program to provide insurance subsidies to households making up to four times the federal poverty level — or about $90,000 for a family of four — is overly generous.
At the same time, health insurance companies, hospitals, employers and other interest groups are gearing up lobbying campaigns to modify the law, parts of which threaten to push up healthcare costs.
Also unclear is how the administration will contend with GOP governors who continue to resist the law and may spurn hundreds of billions of federal dollars to provide insurance coverage.
Several states, including Texas, Florida and Louisiana, have indicated they will not open their Medicaid programs in 2014 to cover all low-income citizens. Most states — including those with Republican statehouses — are expected to expand Medicaid because of the federal money the law provides.
The president could face even more resistance to the law if insurance premiums and other medical costs continue to rise in coming years, undermining a pledge he made in pushing for reform.
"It will be full-speed ahead with implementation. But there could still be some rocky going," said Dean Rosen, a Republican healthcare lobbyist and onetime aide to former Senate Majority Leader Bill Frist.
James Capretta, associate director of the White House Office of Management and Budget under President George W. Bush, said many conservatives would not stop contesting the law. "The fight over the size and scope of government will continue," he said. "Giving up is not an option."
Polls show the public is evenly divided over the legislation. Republicans remain strongly in favor of repeal. And with control of the House, GOP lawmakers could continue to push proposals to eliminate or roll back parts of the law.
Obama in the past has signaled willingness to modify the law. But he has flatly rejected any major retrenchments. As the presidential campaign drew to a close, Obama increasingly defended the law. The president was introduced at one of his final rallies by a father whose 8-year-old daughter got treatment for leukemia thanks to the law, an anecdote he repeated in his victory speech Tuesday night.
Administration officials also insist they will not delay the law, which will allow Americans who don't get coverage through work to buy insurance on Internet-based marketplaces called exchanges. "Consumers in all 50 states will absolutely have access to an exchange come January of 2014," said Department of Health and Human Services spokeswoman Erin Shields Britt.
Under the law, states have until Nov. 16 to tell the department whether they will set up an exchange, a complicated project requiring new data systems, regulations and bureaucracy.
Just 15 states, including California, Maryland and Connecticut, as well as the District of Columbia, have established an exchange, according to the nonpartisan Kaiser Family Foundation. More than a third of the states are expected to reject that option, forcing the federal government to step in.