First, there was uncertainty over a U.S. Supreme Court challenge. Then came the race for the presidency.
Now, California lawmakers say the uncertainty is over and nothing can stop them from bringing health coverage to millions of uninsured Californians under President Obama's signature health care law.
"This removes the last distraction and question from anyone's mind that we won't be launching a dramatic expansion in coverage in California," said Peter Lee, executive director of California's health insurance exchange, a key piece of the expansion.
In Kern County, health care administrators said the election cleared the way for California to continue leading the way in health care reform.
"I was very happy to see the election went to (President Obama) because I feel like we will be able to keep moving forward with health care reform under that administration," said Jacey Cooper, program director for the Kern Medical Center Health Plan.
Lee and other California health leaders also applauded the passage of Gov. Jerry Brown's tax initiative, Proposition 30, saying its success may have prevented additional health cuts at the state level.
More cuts would have complicated the state's implementation of the federal law, whose major provisions debut in 2014 and include the health exchange and an expansion of Medi-Cal, the state's version of Medicaid. More than 2 million people could gain coverage in the first year.
"Prop. 30 provides some breathing room (and) gives us the opportunity for a stable foundation from day one," said Diana Dooley, secretary of the California Health and Human Services Agency.
The way ahead is not entirely clear of potential threats, however. Congressional Republicans have vowed to weaken the law, and upcoming budget negotiations could provide them an opportunity.
California has the most uninsured residents in the country -- about 7 million -- and therefore potentially the most to gain.
Some uninsured residents will be able to purchase federally subsidized insurance through the exchange, which will offer a marketplace of health plans. Individuals and families making between 138 and 400 percent of the federal poverty level, or up to $92,200 for a family of four in 2012, will be eligible for the subsidies.
The exchange plans to open in October 2013 with an open enrollment period, with coverage to commence in 2014.
By 2019, up to 2.1 million Californians could enroll in the subsidized coverage, according to a joint analysis by UCLA and UC Berkeley.
Exchange leaders didn't wait for the Supreme Court or the election to get rolling. They already have awarded a $359 million contract for the development of the online portal and have begun soliciting health plans for the program, called "Covered California."
"Over the coming months, people will very much be looking to California as a model for how an exchange could work," said Larry Levitt, a senior vice president at the Kaiser Family Foundation. "Particularly as states that are somewhat more behind try and catch up, I have no doubt they're going to be calling Sacramento to get some advice."
The Medi-Cal expansion will broaden eligibility for the program by raising the qualifying income level and allowing those who were previously ineligible, such as single adults, to access coverage. Up to 1.6 million Californians could enroll in Medi-Cal under the expansion by 2019.
That process is already under way. About half a million low-income Californians are covered in the "Bridge to Reform," the state's precursor to the Medi-Cal expansion. In Kern County, about 6,700 are enrolled in the Kern Medical Center Plan, a bridge to reform program.
Kern County health leaders said it remains to be seen how the kinks and challenges of health care reform will work out. Clinica Sierra Vista CEO Steve Schilling said adequate "medical manpower" to meet the needs of the newly insured is a major issue. Others agreed.
"Just having coverage doesn't mean you necessarily have access," said Kern Medical Center CEO Paul Hensler. "If you add a lot of demand to the system and don't increase the supply there's going to be a lot of problems."
Clinica is adding seven new facilities and looking at others. Schilling said Clinica will create a facility in urban Bakersfield to house an expanded family medicine residency program. Getting valley students through medical school and bringing them here for their post-graduate education makes it more likely that they will stick around to work in the community, he said.
"We need to grow our own and continue (building) our own capacity," Schilling said.
Jon Van Boening, CEO and president of Bakersfield Memorial Hospital, raised several concerns about how health care reform will play out, such as whether doctors will opt out of seeing patients whose insurance reimbursement rates are lower under the new system.
Still, he said the hospital will continue to provide a high level of quality care "in this new and challenging environment that is being created by health care reform."
"Having more people insured in our country certainly adds more value to our society," Van Boening said.
MORE TO DO
In Sacramento, state lawmakers are preparing for a special legislative session, called by Gov. Brown, to focus on implementation of the health law. Bills approved during the special session take effect more quickly -- 91 days after adjournment -- than those in the regular session.
Work will begin in earnest in January.
In part, California lawmakers have been waiting for direction from the federal government, which soon is expected to release a torrent of regulations and guidance to help states implement the law.
State Sen. Ed Hernandez, D-West Covina and Democratic chairman of the Senate Health Committee, has ambitious plans for legislation, including a measure that the governor vetoed this year. The bill would have, among other things, implemented a key piece of the federal law that requires health plans to cover anyone regardless of pre-existing medical conditions.
Emily Bazar is a senior writer at the CHCF Center for Health Reporting, based at the USC Annenberg School for Communication and Journalism. The center is funded by the nonpartisan California HealthCare Foundation. Deborah Schoch and John M. Gonzales contributed.
Californian reporter Rachel Cook contributed to this article