President Barack Obama's re-election means his overhaul of the U.S. health-care system, opposed by most Republicans, will move ahead in all 50 states, with or without the cooperation of their governors.

State officials who held off implementing some aspects of the 2010 Affordable Care Act now face pressure to make decisions almost immediately. They have nine days to advise the federal government how they plan to manage state-run exchanges created by the law to provide medical coverage to the uninsured, or face a de facto U.S. takeover of their insurance markets.

With Republican candidate Mitt Romney promising to repeal the law, all but 13 governors had taken a wait-and-see approach. Now those that "thumbed their nose" at the president must quickly reassess, said Mississippi Insurance Commissioner Mike Chaney, a Republican who said he will submit a plan for his state's exchange by the Nov. 16 deadline.