WASHINGTON — The future of health care reform loomed like a specter in a bitter campaign fought over the appropriate size and role of government. With President Obama touting his signature domestic achievement and Mitt Romney vowing to repeal it, the 2010 law symbolized the deep ideological divide in Congress and in the country.

Now, with Obama emerging victorious, Republicans failing to take the Senate, and the Supreme Court upholding the legality of the law, the debate around expanding health care to the uninsured is shifting from political posturing to the practical. States must meet their next deadline in just nine days.