It’s important to remember that insurance is regulated to a large extent at the state level.  Insurance commissioners are not appointed by the President or by Congress; they are appointed by governors.  And on Tuesday, Republicans picked up nine seats to control 29 states. Moreover, the exchanges, which still have to be set up, are also state based.  Again, state insurance commissioners will have a lot of power and control to set regulations on how the exchanges will work.  That will make a big difference in how reform functions in the individual insurance market – where most of the uninsured are expected to get insurance.