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After a shaky few years, President Obama's health care legacy looks secure.
His health overhaul law barely made it through Congress and to his desk. Then there were the legal challenges, launched when the ink of his signature was barely dry, that were resolved by a surprising Supreme Court ruling in June.
Even so, former Massachusetts Gov. Mitt Romney vowed to repeal the health law, promising that he would begin dismantling on his first day in office.
That threat, a stretch at best, is now moot.
Over the next four years, the meat of the health law, Obama's signature domestic policy achievement during the first term, will take effect.
"The re-election of Obama and the Democrats holding the Senate will solidify the law in American history," Len Nichols, a health economist at George Mason University told Kaiser Health News. "By 2016 you'll see the vast majority of states with operational [insurance] exchanges and the Medicaid expansion, and we'll be on a pathway to a more humane system." Nichols supported the health law.
There's a lot of work to do.
States that weren't sure about going ahead with insurance exchanges — online marketplaces where people can shop for coverage — have to make a decision now. By Nov. 16, they have to file their plans for them or punt to the feds. As of late September, 24 states still were studying options or hadn't done much to reach a decision, according to the Kaiser Family Foundation.
The deadline looms now so that states will be ready for the start of 2014, when the health law's mandate kicks in. People who don't have health insurance already will have to buy it, or pay a penalty. Government subsidies will be offered to help those with low incomes. And the exchanges are supposed to make it easy to shop for coverage.
Some of the other high-impact parts of the law will also take effect in 2014. There will be a federally subsidized expansion of Medicaid, though states can opt out thanks to one part of the Supreme Court's ruling. Annual limits on insurance coverage will be phased out, and pre-existing conditons can't be used to deny coverage.