By Mary Agnes Carey and Jenny Gold, Kaiser Health News

Now that President Barack Obama has won a second term, the Affordable Care Act is back on a fast track.

Some analysts argue that there could be modifications to reduce federal spending as part of a broader deficit deal; for now, this is just speculation. What is clear is that the law will have sweeping ramifications for consumers, state officials, employers and health care providers, including hospitals and doctors.

While some of the key features don't kick in until 2014, the law has already altered the health care industry and established a number of consumer benefits.

Here's a primer on parts of the law already up and running, what's to come and ways that provisions could still be altered.

I don't have health insurance. Under the law, will I have to buy it and what happens if I don’t?

Today, you are not required to have health insurance. But beginning in 2014, most people will have to have it or pay a fine. For individuals, the penalty would start at $95 a year, or up to 1 percent of income, whichever is greater, and rise to $695, or 2.5 percent of income, by 2016.

For families the penalty would be $2,085 or 2.5 percent of household income, whichever is greater. The requirement to have coverage can be waived for several reasons, including financial hardship or religious beliefs.

Millions of additional people will qualify for Medicaid or federal subsidies to buy insurance under the law.

While some states, including most recently Alabama, Wyoming and Montana, have passed laws to block the requirement to carry health insurance, those provisions do not override federal law.

I get my health coverage at work and want to keep my current plan. Will I be able to do that? How will my plan be affected by the health law?

If you get insurance through your job, it is likely to stay that way. But, just as before the law was passed, your employer is not obligated to keep the current plan and may change premiums, deductibles, co-pays and network coverage.

You may have seen some law-related changes already. For example, most plans now ban lifetime coverage limits and include a guarantee that an adult child up to age 26 who can't get health insurance at a job can stay on her parents' health plan.

What other parts of the law are now in place?

You are likely to be eligible for preventive services with no out-of-pocket costs, such as breast cancer screenings and cholesterol tests.

Health plans can't cancel your coverage once you get sick – a practice known as "rescission" – unless you committed fraud when you applied for coverage.

Children with pre-existing conditions cannot be denied coverage. This will apply to adults in 2014.

Insurers will have to provide rebates to consumers if they spend less than 80 to 85 percent of premium dollars on medical care.

Some existing plans, if they haven't changed significantly since passage of the law, do not have to abide by certain parts of the law. For example, these "grandfathered" plans can still charge beneficiaries part of the cost of preventive services.

If you're currently in one of these plans, and your employer makes significant changes, such as raising your out-of-pocket costs, the plan would then have to abide by all aspects of the health law.

I want health insurance but I can’t afford it. What will I do?

Depending on your income, you might be eligible for Medicaid. Currently, in most states nonelderly adults without minor children don't qualify for Medicaid. But beginning in 2014, the federal government is offering to pay the cost of an expansion in the programs so that anyone with an income at or lower than 133 percent of the federal poverty level, (which based on current guidelines would be $14,856 for an individual or $30,656 for a family of four) will be eligible for Medicaid.

The Supreme Court, however, ruled in June that states cannot be forced to make that change. Republican governors in several states have said that they will refuse the expansion, though that may change now that Obama has been re-elected.

What if I make too much money for Medicaid but still can't afford to buy insurance?

You might be eligible for government subsidies to help you pay for private insurance sold in the state-based insurance marketplaces, called exchanges, slated to begin operation in 2014. Exchanges will sell insurance plans to individuals and small businesses.

These premium subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,856 to $44,680 for individuals and $30,656 to $92,200 for a family of four (based on current guidelines).

Will it be easier for me to get coverage even if I have health problems?

Insurers will be barred from rejecting applicants based on health status once the exchanges are operating in 2014.

I own a small business. Will I have to buy health insurance for my workers?

No employer is required to provide insurance. But starting in 2014, businesses with 50 or more employees that don't provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchange will have to pay a fee of $2,000 per full-time employee. The firm's first 30 workers would be excluded from the fee.

However, firms with 50 or fewer people won't face any penalties.

In addition, if you own a small business, the health law offers a tax credit to help cover the cost. Employers with 25 or fewer full-time workers who earn an average yearly salary of $50,000 or less today can get tax credits of up 35 percent of the cost of premiums. The credit increases to 50 percent in 2014.

I'm over 65. How does the legislation affect seniors?

The law is narrowing a gap in the Medicare Part D prescription drug plan known as the "doughnut hole." That's when seniors who have paid a certain initial amount in prescription costs have to pay for all of their drug costs until they spend a total of $4,700 for the year. Then the plan coverage begins again.

That coverage gap will be closed entirely by 2020. Seniors will still be responsible for 25 percent of their prescription drug costs. So far, 5.6 million seniors have saved $4.8 billion on prescription drugs, according to the Department of Health and Human Services.

The law also expanded Medicare's coverage of preventive services, such as screenings for colon, prostate and breast cancer, which are now free to beneficiaries. Medicare will also pay for an annual wellness visit to the doctor. HHS reports that during the first nine months of 2012, more than 20.7 million Medicare beneficiaries have received preventive services at no cost.

The health law reduced the federal government's payments to Medicare Advantage plans, run by private insurers as an alternative to the traditional Medicare. Medicare Advantage costs more per beneficiary than traditional Medicare. Critics of those payment cuts say that could mean the private plans may not offer many extra benefits, such as free eyeglasses, hearing aids and gym memberships, that they now provide.

Will I have to pay more for my health care because of the law?

No one knows for sure. Even supporters of the law acknowledge its steps to control health costs, such as incentives to coordinate care better, may take a while to show significant savings. Opponents say the law’s additional coverage requirements will make health insurance more expensive for individuals and for the government.

That said, there are some new taxes and fees. For example, starting in 2013, individuals with earnings above $200,000 and married couples making more than $250,000 will pay a Medicare payroll tax of 2.35 percent, up from the current 1.45 percent, on income over those thresholds. In addition, higher-income people will be taxed 3.8 percent on unearned income, such as dividends and interest.

Starting in 2018, the law also will impose a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year and $27,500 for families. The tax has been dubbed a "Cadillac" tax because it hits the most generous plans.

In addition, the law also imposes taxes and fees on several major health industries. Beginning in 2013, medical device manufacturers and importers must pay a 2.3 percent tax on the sale of any taxable medical device to raise $29 billion over 10 years. An annual fee for health insurers is expected to raise more than $100 billion over 10 years, while a fee for brand name drugs will bring in another $34 billion.

Those fees will likely be passed onto consumers in the form of higher premiums.

Hasn't the law hit some bumps in the road?

Yes. For example, the law created high-risk insurance pools to help people buy health insurance. But enrollment in the pools has been less than expected. As of Aug. 31, 86,072 people had signed up for the high-risk pools, but the program, which began in June 2010, was initially expected to enroll between 200,000 and  400,000 people. The cost and the requirements have been difficult for some to meet.

Applicants must be uninsured for six months because of a pre-existing medical condition before they can join a pool. And because participants are sicker than the general population, the premiums are higher.

Enrollment has increased since the summer, after the premiums were lowered in some states by as much as 40 percent and some states stepped up advertising.

A long-term care provision of the law is dead for now. The Community Living Assistance Services and Supports program (CLASS Act) was designed for people to buy federally guaranteed insurance that would have helped consumers eventually cover some long-term-care costs. But last fall, federal officials effectively suspended the program even before it was to begin, saying they could not find a way to make it work financially.

Are there more changes ahead for the law?

Some observers think there could be pressure in Congress to make some changes to the law as a larger package to reduce the deficit. Among those options is scaling back the subsidies that help low-income Americans buy health insurance coverage. The amount of the subsidies, and possibly the Medicaid expansion as well, could be reduced. 

It’s also possible that some of the taxes on the health care industry, which help pay for the new benefits in the health law, could be rolled back. For example, legislation to repeal the tax on medical device manufacturers passed the House with support from 37 Democrats (it is not expected to receive Senate consideration this year). Nine House Democrats are co-sponsoring legislation to repeal the law’s annual fee on health insurers.

Meanwhile, the Independent Payment Advisory Board (IPAB), one of the most contentious provisions of the health law, is also under continued attack by lawmakers. IPAB is a 15-member panel charged with making recommendations to reduce Medicare spending if the amount the government spends grows beyond a target rate. If Congress chooses not to accept the recommendations, lawmakers must pass alternative cuts of the same size.

Some Republicans argue that the board amounts to health care rationing and some Democrats have said that they think the panel would transfer power that belongs on Capitol Hill to the executive branch. In March, the House voted to repeal IPAB but that bill did not get past the Senate.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Updated at 5:50 p.m. ET, Nov. 9: There’s nothing like a deadline to focus the mind and states have a good one coming up next week – they have to decide if they're going to run their own health insurance marketplaces, called exchanges, or have the federal government do it for them. 

But they got a little break late Friday -- if they do decide to run their own exchanges, they'll have until December 14 to submit their plans to the federal government.

It’s a big decision and a big responsibility. One of the main goals of the 2010 health reform law is to get more people covered by health insurance, so they can get medical care when they need it, and so they get care earlier, before easy-to-treat conditions like high blood pressure can cause expensive strokes or heart attacks.

The exchanges – think Travelocity for health insurance – will provide a mechanism for more people to buy insurance. They’re supposed to provide a side-by-side comparison on price, what’s covered and how much you might have to pay out of pocket for a doctor’s visit. They’ll also be a route for people to get a little extra cash from the federal government to buy insurance; the health care law provides for a generous federal subsidy for many, if not most, buyers.

The states had two good excuses this year to procrastinate on exchanges. First of all, there were three major challenges to the law that went all the way to the Supreme Court. Many governors and state legislators were gambling that the Supreme Court would declare the law unconstitutional. It didn’t. Now the Nov. 16 deadline looms.

“This deadline is smoking the states out,” says Dan Mendelson of consultants Avalere Health.

But Health and Human Services Secretary Kathleen Sebelius softened the deadline a bit late on Friday. "The deadline for a Declaration letter for a State-based exchange remains Friday, November 16, 2012," she wrote in a letter to governors. "However, today, in order to continue to provide you with appropriate technical support if you are pursuing a State-based exchange, HHS is extending the deadline for State-based Exchange Blueprint application submissions to Friday, December 14, 2012."

When it ruled in June, the Supreme Court said states could decide whether to offer Medicaid – the state-federal health insurance plan for the low-income – to more people. But the rest of the law stood, including the exchanges requirement. Still, there was another possible way out – the election.

Republicans promised that they’d repeal the entire health reform law if they won in this week’s election. Now that Mitt Romney has lost to President Barack Obama and the Democrats have kept their control of the Senate, any chance of killing the Affordable Care Act is now dead. 

"Obamacare is the law of the land," House Speaker John Boehner said in an interview with ABC News on Thursday.

So far, only 13 states and Washington, D.C. have said they’ll build a health insurance exchange. Eight have said they absolutely will not, and 25 states have been sitting on the fence, says Kelly Barnes, U.S. health industries leader at PricewaterhouseCoopers.

"My administration will not partner with the federal government to create a state-federal partnership insurance exchange because we will not benefit from it and implementing it could cost Kansas taxpayers millions of dollars," Kansas Governor Sam Brownback said in a statement Thursday.

Some groups are also urging governors to defy HHS. “States can and do have the power to reject federal attempts to compel their action. Governors should use that power to tell the federal government 'no'," Nicole Kaeding of the group Americans for Prosperity said in a letter sent Friday. “By creating an exchange, states will serve as de-facto administrators of the federal government implementing its rules, regulations, and mandates.”

States that don't set up their exchanges will have to submit to what the federal government does for them.

Avalere predicts 20 states will be ready to run their own exchanges when the bulk of the health reform law takes effect on Jan. 1, 2014. “The consumer will have access to an exchange by 2014,” Mendelson said. “One way or another, this administration has to make sure that everyone who wants to purchase insurance can.”

To make sure that people don't wait until they are sick to buy health insurance, the 2010 health reform law provides for fines on a sliding scale for people who don't buy. And people who want to switch from their employer's insurance can.

States may have been hoping to escape the looming responsibility, but that doesn’t mean they have been doing nothing. “I think there are more contingency plans out there than probably people have declared,” Barnes said.  “A state like California, that has been planning all along, will have a higher level of organization.”

Waiting on the rules
Some Republican governors have done a fair bit of planning, including Bob McDonnell of Virginia and New Jersey’s Chris Christie. But many want the Health and Human Services Department to give them the rules for the exchanges, and to spell out what a federally run exchange would look like.

That would help them choose. Many have also asked if they can do a hybrid, with the state running part and the federal government running part of the exchange.

The federal government hasn’t published those rules. They are currently awaiting approval at the Office of Management and Budget. "We intend to issue further guidance to assist you in the very near future," Sebelius wrote the governors."This administration is committed to providing significant flexibility for building a marketplace that best meets your state's needs," Sebelius added.

“It’s driving the insurance companies crazy to not have any clarity about what they need to be offering in the exchanges,” Mendelson said. “Having said that, when push comes to shove, the insurers want to be offering products in the exchanges. They will rise to the challenge.” After all, the exchanges could mean more than 20 million new customers for insurance companies.

Right now, about 48 million Americans are going without health insurance, according to the Census Bureau. That’s more than 15 percent of the population.

About 55 percent of Americans are covered through an employer; 31 percent have a public insurance plan such as Medicare or Medicaid, and 10 percent buy their own health insurance.

23 million likely will get insurance through exchanges
The Congressional Budget Office predicts that 23 million people who don’t have health insurance now will get it on one of the exchanges. More than 18 million of them will qualify for a federal subsidy averaging $6,000 a year per person. People earning up to four times the federal poverty level can get a subsidy: that’s an income of $92,000 a year for a family of four.

But it’s going to be confusing, especially for people who have never had to wrangle with an employer’s open enrollment process before. “If you have had employer-sponsored insurance, at least you are familiar with the terms,” said Barnes. “But there is also a big tranche of buyers who have never had access to insurance before. It’s a less sophisticated consumer.”

Many people will go for bare-bones coverage, Barnes predicts. “Price is going to be the first selector in this round,” she said. “When all else fails, you buy on price.”

Some people who now have employer-covered insurance are doing that anyway. There’s a clear trend for employers to offer less, and to require their employees to pay a bigger share of their health insurance coverage. “It is definitely true that employers are paying for less and less,” Mendelson says.

“They are increasing co-pays and making it expensive for patients to use medical services. But even with those trends, the benefits available in the exchange are likely to be less generous and less robust than what employers offer today.”

Nonetheless, Mendelson says the exchanges will set the standards going forward. “These are going to be solid commercial insurance products offered by leading health insurance companies,” he said. “They are widely seen as the future.”

It will pay, he said, for the companies to make it easy to understand what they’re offering for sale on the exchanges.

Related links:

Boehner: 'Obamacare is the law of the land'

A consumer's guide to health reform, post-election 

Supreme Court ruling leaves poorest Americans at risk

More workers opt out of company health plans

A quarter of kids live in families struggling with medical bills

One of the biggest winners Tuesday night was health reform. Now that President Barack Obama has won a second term and kept a Democratic majority in the Senate to back him up, Republicans have lost any chance at repealing his biggest domestic initiative.

“Health reform goes ahead,” Timothy Jost, an expert on health law at Washington and Lee University, told NBC news. “It has survived two near-death experiences, with the Supreme Court decision (in June) and now with the election. Now it is time to move forward.”

For most Americans who get their health insurance through their employers, that could mean some significant changes as they are asked to make more and more of their own decisions about how coverage they want.

Republican analysts agree. “What it means is implementation of the law,” said Christopher Condeluci, a former Tax and Benefits Counsel to the Senate Finance Committee who is now at Washington law firm Venable LLP.

It doesn’t mean smooth sailing, however. Many rules have yet to be rolled out – and there is little time to do that before the law begins to take full effect in 2014.

Much of the law’s implementation is up to the states. And Republicans still control the House, which means they hold the initiative on setting the budget. As they’ve done over the past four years, they can hold the budget hostage. And this year the administration and Congress will have to negotiate on an especially tricky budget issue – the fiscal cliff.

Now that he's won, the six splitting headaches waiting for Obama

Unless Congress makes a budget deal fast, $600 billion in tax increases and spending cuts - known as the fiscal cliff – go into effect in January. Some of the money used to fund the health care law will undoubtedly be on the table for the last-minute bargaining. The Congressional Budget Office has projected the law will cost about $1.2 billion over 10 years.

“I would expect that Republicans are going to push pretty hard to get some money out of the Affordable Care Act,” Jost said. “There is a lot of money there,” Condeluci agreed.

Some parts supposedly cannot be touched – the money to be used to subsidize health insurance for people who want to buy it on the new marker provided by health insurance exchanges, for instance. People who earn up to 400 percent of the federal poverty level, or about $92,000 for a family of four, would be able to get a subsidy and conservatives may want to bargain against some of this money to try and cut the federal deficit.

And the federal government has promised to pay the full cost of expanding Medicaid in the states for the first few years. It’s not clear how much this will cost until states choose what to do. The Supreme Court ruling that upheld the health care law in June made it clear that states get to decide whether they’ll offer Medicaid to more people. Congress may want to try to negotiate against that money, also.

But Harry Conaway, who heads the Washington office of consulting group Mercer, notes that budget projections show the Affordable Care Act will save money over 10 years, so it may be risky to play with it too much.

Victorious Obama 'more determined' in face of challenges

States that have refused to set up their own health insurance exchanges can expect the federal government to do it for them. But it now has just under a year to get that done.

“The administration has a mountain to climb,” Condeluci said. “There are a lot of rules that it appears that they slow-walked until after the election. I understand why they did slow-walk those rules. Those rules are related to some very, very important parts of this law.”

One rule everyone is waiting for is the so-called essential benefits package -- the list of minimum requirements for plans to cover.

Condeluci worries that the process will be rushed now, which may not allow for proper consideration of public comments on administration proposals.

“We haven’t seen the rules on the federally facilitated (health insurance) exchange. We don’t even know if will be up and running by open enrollment, which is October 2013,” Condeluci said.

Conaway thinks the administration may have to delay some of the deadlines. "The Obama administration will have to make an assessment later this year or early next year about whether a 2014 implementation will go smoothly or be chaotic and disruptive," he said.

Slideshow: Election 2012

Kevin Lamarque / Reuters

Campaigning with Mitt Romney and Barack Obama, voting and election results.

Launch slideshow

What it means for you

Mercer's Tracy Watts says employers are already beginning to make changes to what they offer workers. "Over the next several years everybody will continue to see changes to their benefits," she said. More people may see bare-bones plans, because of changes in the rules about how much employers have to cover.

The 2010 health care law actually lowers the average actuarial value for a plan -- the percentage of the total bill that an employer has to cover. On average, a health insurance plan now pays for about 85 percent of the costs, with the patient making up 15 percent. The health reform law says plans only have to pay 60 percent -- meaning some people may end up being on the hook for 40 percent of their costs with a new, slimmed-down plan.

"Let's say  you have an outpatient procedure that costs $3,000," Watts said. A new-style plan might require a $2,000 deductible and 50 percent co-insurance, meaning the patient has to pay $2,500 for the procedure and the employer picks up $500. But, she adds, employees will have the option to add better coverage a la carte. The difference is the employers will no longer simply offer a single package -- people will have to work out what particular pieces of coverage they want, and pay a little more each month for the extras.

Watts says Mercer's surveys show that 90 percent of employers who currently offer health insurance to their workers will continue to do so.

Another Supreme Court challenge?
Rules that insurers are waiting to see include the community rating requirements — these are the different premiums that insurers may charge people based on their sex, age and health status. For instance, the law aims to stop the common practice of insurers charging women more than they charge men of similar age and health status. But they will be able to charge people higher premiums as they get older, and just how much more needs to be laid out.

There’s also the guaranteed issue rule – this will require insurers to cover people even if they have existing health conditions. Again, this isn’t detailed yet.

And then there are the states. Many Republican governors are already resisting some of the most important aspects of healthcare reform, such as expanding Medicaid to cover people who can’t easily get health insurance any other way.

“At this point it really comes down to the states,” Condeluci said. “The biggest bogey out there is what the states are going to do. We could have a situation where states continue to resist implementing the law.’

That, Condeluci predicts, could even create another Supreme Court challenge to the law.

“Dare I say it -- if their resistance continues, we will have a federalism issue where a federal law is essentially telling a state to do something and the state is saying ‘no’ to that federal law. Arguably, that would have to be decided by the Supreme Court.”

Jost is a little more hopeful. “I think we will see states move toward a more cooperative and less confrontational relationship,” he said. “One hopes that at some time, people are going to act practically rather than ideologically.”

There could also still be friction over the law’s requirements that insurers and employers provide birth control coverage free of charge to women. Conservative employers continue to challenge the requirement in court.

Lisa Maatz, policy director for the American Association of University Women, thinks that issue galvanized many women voters – especially when some conservatives framed the issue as one of religious freedom as opposed to women’s health.

“The conversation itself was not only disheartening, but it also shook women down to their toes,” Maatz told NBC News. “It was an eye-opener for younger women who never believed such rights could be taken away, and a galvanizer for older women as well.”

Related links:

• State elections key to health reform
• Free birth control starts under health care law
• Who falls through the cracks when states don't expand Medicaid
• Much left to do on health reform
• Supreme Court upholds health care law

More election coverage from NBCNews.com:

• Obama wins re-election; Ohio, Iowa, Wisconsin prove pivotal
• Democrats gain in Senate with wins in four states
• Rape remarks sink two Republican Senate hopefuls
• In costliest-ever Senate race, Warren beats Brown for Mass. seat
• Maine's Harley-riding King vowed to 'shake up' D.C.
• Republicans to maintain control of House, NBC News projects
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• In 11 governor races, it's about jobs and taxes
• Majority of voters see American on wrong track

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