As we awaken, bleary-eyed after a late night of watching election returns, it is clear that our national legislative bodies have taken a decisive step to the right.  With many of the newly-elected running specifically against “Obamacare,” it is almost certain that changes to that legislation will soon be in the works.

Not that long ago, we were asking similar questions about the future of healthcare reform after the victory of Scott Brown.  At that time, it focused the Democratic majority to move the legislation forward.

What is the realistic outcome of yesterday’s elections on the Healthcare Reform law?

First and foremost, reform is not going away – at least not entirely.  The problems that initiated the push for healthcare reform haven’t changed.  President Obama will prevent any outright repeals of the legislation while still in office.  And let’s face it, there aren’t any other alternative plans on the table at this stage that create a sustainable healthcare system for the long run.

At the national level, the attack on health reform will come from two directions – budgetary starvation and general gridlock.  The line in the sand will likely come around the Federal budget where legislators will attempt to kill components of the law by removing funding from the budget.  Newly-elected members of Congress are already discussing publicly how they might avoid complete government shutdowns during what promises to be a difficult budgeting process.

Health reform may face greater challenges from state governments than it does at the federal level.  In addition to court battles over state requirements under the law, there are many more subtle ways that states can undermine its principles and effectiveness.  As the number of anti-reform governorships increases, state insurance commissioners who are ultimately responsible for implementing and enforcing many components of healthcare reform may simply choose not to do so.

The experiments in systemic and payment reform are the most likely components of the legislation to survive the maelstrom.  Expect to see Accountable Care Organizations, Payment Bundling pilots, Patient-Centered Medical Home pilots and two new institutions, the Center for Medicare and Medicaid Innovation and the Independent Payment Advisory Board, continue to be on the agenda.

The highest costs components of reform along with the taxes intended to pay for them are most at risk.  These include the various programs to expand toward universal coverage, coverage mandates, and taxes on “Cadillac” health plans.

And the battle for consumer sentiment continues with Dr. Mehmet Oz stepping onto Californians television sets after the election last evening, stating that it’s time to “get over it.”  Although weighing in with his support and educating the public before the election would have been much more helpful to his cause.