At the point that the Patient Protection and Affordable Care Act (PPACA) was signed into law in March of 2010, there were three major threats to its prospects for survival and eventual success. The first and most immediate was litigation that would successfully challenge the financial lynchpin of the PPACA–the so-called individual mandate that requires that all individuals either be covered by or carry health insurance. Absent that requirement, which is common to all nations that provide universal coverage through a mixture of private insurance and public programs, the most popular and in many ways essential provisions of the PPACA would be made fiscally unviable. In June of 2012 the U.S. Supreme Court in a narrow decision upheld the Constitutionality of the individual mandate and the PPACA thus survived its first deadly threat.

The second major threat to the PPACA’s prospects for survival has been the Republican Party’s vows to repeal the PPACA just as soon as they were able to gain majority control of the U.S. Senate, the White House, or possibly both. In fact, in an essentially symbolic series of votes in the months preceding the election, the Republican majority in the U.S. House of Representatives repeatedly passed legislation that would have repealed the PPACA had not the Democratic Party controlled the Senate and the Presidency. By late evening yesterday, it was clear that the nation had re-elected President Barack Obama to another four year term and the Democrats had retained control of the Senate. Following these results, it is very clear that even the most ardent of the PPACA’s critics in the Republican Party are conceding that “Obamacare” will now remain in place as the law of the land–thus the PPACA has now survived its second deadly threat.

We should all take a moment to ponder the historical significance of an African American President’s election to a second term despite the national unemployment rate of nearly 8 percent and also having signed into law the most sweeping redistributive social welfare legislation in almost 50 years. Then having done so, we should then consider the remaining threat to the PPACA’s prospects for meaningful survival and success as fundamental health care reform that extends universal coverage to all Americans –the long and tortuous road ahead through state-by-state implementation of its essential provisions. Most significantly in this regard, is the PPACA’s reliance on the willingness of the individual states to each extend their Medicaid eligibility criteria up the income ladder to encompass not just the poor, but also to low income individuals and families that earn just enough to stay above poverty line but enough to afford even subsidized private insurance. While the PPACA provides the individual states with the federal funds to expand Medicaid coverage to low income individuals and families, in a defeat for the Obama administration the U.S. Supreme Court also ruled last summer that the PPACA could not compel states to extend their Medicaid coverage to the low income. Thus, a very crucial component of the PPACA’s general strategy to achieve universal coverage is held hostage to the ideological preferences the individual states despite the PPACA’s having survived both Supreme Court litigation and its final threat from national elections. Not surprisingly, many “red state” politicians have already vowed to reject federal supplemental Medicaid funds rather than extend Medicaid coverage to the low income uninsured and thus help the PPACA achieve its central policy goal of universal access to health care. Although the history of the (in many ways comparable) State Children’s Health Insurance Program legislation suggests that expanded Medicaid coverage will eventually  encompass even the reddest of red states, it is unlikely that the PPACA will meet its primary policy goal of near universal health insurance coverage by the end of the decade.

In sum, there are three take-aways from yesterday’s historic election with specific reference to the future of the Patient Protection and Affordable Care Act:

1) The re-election of President Barack Obama and the Democratic Party’s retention of control of the Senate assures that the PPACA will remain the law of the land. In particular, it became abundantly clear that that repeal of the PPACA is not, in the final analysis, a viable way for the Republican Party to win future elections. The PPACA and fundamental health care reform are thus here to stay.

2) National politics are not local politics, and to the extent that there is significant ideological opposition to the PPACA at the state level both its major policy goals and speed of implementation will be impeded.

3) Taking the long view, as near universal health insurance coverage gradually becomes the norm among states rather than the exception, even the most conservative states will be compelled to adapt their partisan politics to the realities of public preferences for a basic health care safety-net. Another way of saying this is that Obamacare will outlast its ideological opposition.