Like it or not, President Barack Obama and House Speaker Nancy Pelosi have managed to pass a comprehensive health insurance reform bill, against long odds. The big question is, what happens now?

The vast majority in the insurance business don't like this legislation, and understandably so, since it focuses practically all of its attention on the industry, without reforming the way health care is delivered.

It also fails to offer medical malpractice insurance relief, guaranteeing that defensive medicine will continue to be practiced, driving up costs through the ordering of questionable tests. Meanwhile, the penalties for not buying mandated coverage is way too small to coax everyone into the system.

But these shortcomings can be repaired, and there is still plenty of time to make fixes–as many parts don't go into effect for a few years. But this is only feasible if the Republicans engage the Democrats in a proactive way in good faith, rather than cutting off their nose to spite their face.

The battle over health reform should not end with this bill's signing by President Obama. Indeed, this should be just the beginning of a difficult but ongoing dialogue about how to improve the legislation in terms of cost control and tort reform. Now that we have the foundation of universal coverage, we need to keep building upon it and make sure all the working parts come together to insure everyone without bankrupting the country.

This is, perhaps, nothing but a pipe dream in such a politically toxic culture. Opponents of health reform are unlikely to seek compromise with those who voted for this bill. Instead of accepting the reality of the situation and stepping up to make this an evolving process, those in “the no” will probably do all they can to stall implementation, overturn the measure someday, and, if all else fails, demonize it and anyone associated with its passage.

Therefore, expect constitutional challenges over a federal mandate to buy coverage. Expect certain states to balk at creating the health insurance exchanges called for under the bill. And certainly expect the new law to be the key point of contention in this November's mid-term elections, in which Republicans hope to retake control of Congress as a prelude to retaking the White House in 2012.

I think opponents might be surprised to find resistance to any calls for repeal. I can't imagine them winning many votes campaigning on the platform that insurers should be allowed to exclude people with pre-existing conditions, or drop coverage for those who get sick. And once people realize they might get subsidies from Uncle Sam to help buy insurance, anyone who wants to revoke such financial support will have a hard sell.

I'm not a big fan of this bill. It takes too long for the key provisions to take effect, with tens of millions left uninsured in the meantime. It lacks a public option to provide some healthy competition for private carriers. And, as I've argued before, we all would have been better off with an assigned risk pool to cover the uninsured, with policyholders split up among carriers writing in a given state, according to their market share.

In addition, there should be a major effort to standardize and regulate what the medical profession charges for its services, along with meaningful malpractice reform. And penalties for failing to buy coverage should be much higher.

But be that as it may, I give the Democrats credit for taking a gutsy vote in support of a principle I firmly believe in–that everyone should have insurance coverage regardless of their job status, medical condition or financial situation. I don't believe the Republicans share that goal. And therein lies the major point of contention, preventing any attempt at compromise.

This bill could have been a lot worse for the insurance industry. There is no public option to potentially drive carriers out of business. Private insurers will see billions in additional premiums, thanks in large part to government subsidies. And agents–whose advice will be needed more than ever to navigate this cockamamie system–are not being forced out of the market.

But this bill could also be a lot better. Rather than destroy it, leaving millions uninsured, I hope the industry and the Republican party work to make it better for everyone. Rather than “start over,” let's start building on what we already have in place.

What do you folks think?