Proponents of health care reform let out a big sigh of relief when the Supreme Court decided in June to uphold President Barack Obama's landmark health care legislation, the Affordable Care Act (ACA).
But as Election Day began to draw near, they started holding their breath again. Republican challenger Governor Mitt Romney had promised to start work on repealing the ACA on his first day of office – per his campaign website, he said he'd "issue an executive order that paves the way for the federal government to issue Obamacare waivers to all 50 states."
That was followed by a vow to "work with Congress to repeal the full legislation as quickly as possible."
Any apprehension about that among ACA advocates went away on Tuesday night, of course, when the nation learned Obama would remain the 44th president of the United States.
But could his former challenger have done it? How simple would it have been for a President Romney to undo the herculean legislative effort the Obama Administration had undertaken to get health care reform passed?
According to Brietta Clark, a professor at Loyola Law School who specializes in health care law and access issues: not that simple.
"It would have been hard for me to imagine that happening, especially given [the ACA has] some measures already in place that people are excited about," she said. "It's much harder to take away" – that is, to repeal the law – "than it is to prevent passage in the first place."
In other words, opponents of the ACA had a better shot of blocking health care reform when it wasn't law yet. Now that it is, though, and now that any threats of an executive-backed reversal of the law won't be happening anytime soon, Clark says the next challenge is the most important one.
"Implementation is where we're going to see whether or not reform will be successful," she said. In that regard, she added, Obama is the best chance the U.S. has.
"You need an executive that is committed, aggressive, thoughtful and hands-on," Clark explained. Because of that, she said, Romney could have caused much more damage to the ACA by "virtue of his executive position" than by the difficult process of repeal.
"For health care reform, the regulations matter," she said. "People who are regulating it matter. Its success depends on how it gets implemented. This is now the real test. Having somebody in that office who didn't really want to implement it in ways that were effective" – meaning Romney – "that would have undermined it."
Also complicating any notions of repealing the law was the fact that it's hard to do that without strong congressional support, Clark said – hardly an easy feat in the current über-partisan political landscape. On top of that, she said that when politicians reject one idea, people expect them to provide an alternative.
"That's why you heard Republicans saying among themselves, 'You can't just talk about repeal – you have to talk about repeal and how you would replace it'," said Clark. The "bottom line," she said, is there was no way to simultaneously take away ACA provisions that were offensive to Republican sensibilities and leave in place the ones people did like.
Dr. Felix Aguilar, the current chief medical officer of South Central Family Health Center and incoming president and CEO of UMMA Community Clinic, called Obama's victory a "vindication."
"A sizable number of our patients will benefit from increased access to health care," he said. "Our work is central to the Affordable Care Act."
The ACA calls for increased funding to community health clinics like the one where Aguilar works, and had it been repealed or even adjusted, Aguilar believes "the funds that are given to community health clinics would have stagnated or decreased." He also believes the insurance exchanges, like the one that will open up in California next fall, would have been ultimately shut down.
Under Romney's proposed health care plan, Aguilar guesses "we would have probably had a greater number of the uninsured." He added that he wouldn't go as far as to say that a country led by Romney would have gone backwards, but he thinks it would have made for a pretty difficult future across the health care spectrum, especially for the poor and underserved.
But while the current outlook on health care access can seem pretty bleak – despite any strides made by the ACA – Clark indicated that last night's election means Aguilar doesn't have to worry about health care reform being reversed.
"You have current politics and the whole wave of history of how we resist real reform in changing health care – both of those things came together to make it incredibly difficult [to pass the ACA]," she said. "By the same token, it would have been challenging to repeal."