The first reaction of Dr. David Bronson, president of the American College of Physicians, to the Nov. 6 election results was one of relief -- but perhaps not for the reason you might think.

Bronson works as president for Cleveland Clinic Regional Hospitals, in the heart of the 2012 key battleground state of Ohio.

"Most of us, we were just happy it's over," Bronson said a few days after the election. "We were inundated with robo-calls and emails. You couldn't watch television any more for the political ads."

But as far as his professional reaction to the election, Bronson said the re-election of President Barack Obama means that health care reform will continue to roll out in the United States. The concern had been that Republican candidate Mitt Romney would, if elected, either move to repeal health care reform or act to block its implementation.

"The Affordable Care Act is the law of the land, and now we need to move quickly forward with its provisions to get Americans insured," Bronson said.

With Obama's election, however, Bronson expects the real struggle over health care reform to devolve down from the federal level. "The action is at the level of the states now," he said. "Each state has to make its own decision as to what it's going to do."

Governors must declare by Dec. 14 whether they plan to implement the Affordable Care Act by creating a state-run health insurance exchange. The deadline was to have been Nov. 16, but at the last minute the Department of Health and Human Services announced the extension. Those states without an exchange will have one imposed on them by the federal government.

A number of Republican governors -- Rick Perry of Texas, Rick Scott of Florida and Robert Bentley of Alabama among them -- have gone on record saying they will not help set up the exchanges in their states.

Also, as a result of the Supreme Court's ruling this past summer on the Affordable Care Act, states must decide whether they will take part in the expansion of Medicaid that is part of the health care law. The ruling gives states the latitude to opt out of the expansion, which could leave millions uninsured.

"We're concerned that the provisions for Medicaid are implemented," Bronson said. "We think it's the right thing to do." He added that ACP argues in favor of Medicaid expansion on medical, financial and moral grounds:

• Medically: Studies have shown that expanding Medicaid reduces mortality and saves lives.
• Financially: States will be able to add people to their Medicaid rolls with the federal government footing much of the bill for the first years of implementation.
• Morally: People should be able to receive the medical care they need without stress or worry.

Bronson said he hopes that, if nothing else prevails, the financial argument will win the day.

"I'm hopeful in the end they'll realize this is a good deal," he said of recalcitrant states. "It doesn't cost them anything for quite a while, and in the long run picking up these people will extend their budgets. We believe it's a deal too good to turn down."