Anthony Wright is executive director of Health Access California, the statewide health care consumer advocacy coalition. He blogs daily at the Health Access Weblog and is a regular contributor to the Treatment.

Maybe it’s good that right after President Obama’s health reform signing ceremony, the Senate went right back to work to improve it. It sends the important signal that this isn’t the end of health reform, but the beginning of a new phase. 

The “reconciliation” changes—those passed by the House and now being considered by the Senate—are crucial and needed, from increasing affordability subsidies for low- and moderate-income families, to fully closing the gap in the Medicare prescription drug benefit.

But even after this package is signed by the President, hopefully in the next week, the work under health reform continues… or rather, it explodes. Instead of being concentrated in Congress for just over a year, health reform will spur frenetic activity over the next five years across the nation, at both the federal and state level, in venues both legislative and regulatory.

The work that needs to be done at the federal level, especially at the Department of Health and Human Services, is immense. But the much of the action will also shift to the states, who have traditionally taken the lead on two central components of health reform: insurance regulation, and the administration of public coverage programs. With federal standards and guidance, each state has a role in everything from expanding and streamlining its Medicaid programs, to setting up the new exchanges which will provide a new, regulated market for consumers to purchase coverage.

In essence, the bill spurs 50 different health reforms. While some Attorneys General grabbed some headlines in filing suit against the reform, other states are already at work implementing—and improving—health reform. Some may decide to take advantage of the federal matching funds available to expand coverage early. Others may institute more aggressive insurer oversight.

On the same day that President Obama signed health reform, California’s Assembly Health Committee passed several relevant bills. One measure, AB2470 (De La Torre), would implement the health reform’s immediate ban on rescissions—the odious insurance company practice of retroactive denial of coverage.

The Committee also approved a concept not in federal reform, AB2578(Jones/Feuer), to institute rate review and regulation. The President endorsed the idea and Senator Dianne Feinstein authored a bill at the federal level, but could not be added through the reconciliation process. While there’s hope it can be considered and passed in the near future in the Senate, the renewed attention has given the concept of political boost at the state level as well—it passed a committee where it had stalled just a year ago.

Another element not included in the final reform package was the public health insurance option. While there will be several renewed Congressional efforts to add such an option, we’ve had a state proposal here—SB56(Alquist)—in California for several years. Reform’s passage gives the public health insurance option bill both a political boost, and a policy framework for the concept to fit into. (Without the new insurance regulation and exchanges, a public option would have had to adopt the same practices as the private insurers to be competitive.)

There’s many more ideas and bills, but that gives you a taste of the challenge and opportunity of the next few years. This effort to implement and improve is not just for good policy, but good politics. Those who support health reform can’t be content with defending reform—a good offense is a good defense, telling voters how they would build upon a good reform to make it better.

So the work continues, if not expands, as the focus gets distributed to state capitols. I hope that the attention does not dissipate, as the crucial work just begins to fulfill the promise of health reform.