States including Maryland can move with more certainty to insure their poor, and the federal government can require others to buy health coverage after the Supreme Court upheld President
's landmark health care law Thursday.
The highly anticipated decision is expected to add millions to the health insurance rolls, including Lashonda Edwards of
, who lost her coverage when she was laid off from her receptionist job in 2010.
"I should be able to get the care I need," she said. "Health insurance should be for everybody because everybody needs it."
The court case had stalled efforts across the country to fully implement the Affordable Care Act and had called into question benefits already put in place, such as coverage for young adults on their parents' policies, more generous benefits as caps on coverage were lifted, and insurance for children with pre-existing conditions.
Maryland had banked heavily on the law's withstanding judicial scrutiny, moving ahead of other states in creating an exchange where individuals and small businesses could buy coverage, and expanding its
The state's leaders said the high court's decision gives them the authority and funding to finally implement provisions of the law, which mostly takes effect in 2014. In the first year, they estimate that one-third of 750,000 uninsured residents will gain coverage.
"Today is a big victory for millions of Americans who don't have access to health care and will be able to afford care," said Lt. Gov. Anthony G. Brown, who has led the state's reform efforts. "This will make a difference in the lives of that 26-year-old with a pre-existing condition or that person who couldn't afford care. No one will worry that the cost of care will drive them into bankruptcy. Those days are over."
Critics of the law, including 26 states that brought the Supreme Court case as well as local conservatives, expressed disappointment with the ruling. Some called for Congress to repeal the entire law, and others denounced it as a new tax.
The law hinged on an "individual mandate," or a requirement that all Americans buy health insurance or face a penalty. The court, led by Chief Justice
, ruled 5-4 that Congress had the power to implement such a tax. The challengers had said the mandate was an unconstitutional overreach.
Congress also authorized the creation of statewide exchanges where the nation's 50 million uninsured Americans could buy coverage, many with the help of federal subsidies included in the law. Maryland stands to gain more than $400 million through these subsides, according to local estimates.
Others living under 138 percent of the federally established poverty level — about $30,000 for a family of four — will gain coverage through an expansion of Medicaid, though the court limited Congress' ability to force the states to add to their rolls. The court said the states could reject new federal money for Medicaid without jeopardizing the funding they already receive for the federal-state program.
Edwards expects to gain coverage either through the Medicaid expansion or with a subsidy on the exchange.
The 29-year-old was born with
but can't get proper treatment because her insurance is too limited. It does not cover the specialists she needs to control her disease, which she fears will grow worse and lead to expensive emergency room visits.
"I was told to see a hematologist, but it's $200 just for one visit, not including the tests," she said.
, 51, also expects to gain coverage with the court decision, which means no more non-emergency trips to the hospital for care.
The Baltimore man lost his job two years ago as a case manager at a social-services organization, along with health care for himself and his wife, Darline. Both have pre-existing conditions and have limited options for treatment.
"Health care is so important," he said. "It's scary to watch your health decline. And we know it's not ideal, but we've been using the emergency room as a conduit to care. That puts the burden on the taxpayers. … Now we are optimistic we can get good insurance."
There are plenty of Marylanders and Americans in the same situation as Edwards and Williams, said Kathleen Westcoat, president and CEO of HealthCare Access Maryland, which helps people connect with coverage. Once they lose their jobs, they still may not qualify for Medicaid or for private insurance because of a pre-existing condition.
HealthCare Access' client list jumped to 125,000 this year from 90,000 just a couple of years ago because of the downturn in the economy, she said.
"When they get very sick and they're uninsured, we all pay through our premiums," she said.
Health care reform will enable her group to help 50,000 residents gain access to care through Medicaid and as many as 80,000 to buy insurance with subsidies on the exchange, she said.
Maryland officials had pledged to find ways to continue implementation of some provisions if the court struck down the health care law but acknowledged that funding would have been an obstacle.
And though some insurers had pledged not to eliminate benefits they had already begun to offer under the law, state officials said they would not have been able to tell them to continue covering those with pre-existing conditions.
"There are some tremendous opportunities and resources the law provides that we would have lost," said Joshua M. Sharfstein, state secretary of health and mental hygiene. "We would have tried to move forward, but how successful it would have been I couldn't say."
Some say that spending so much money to cover so many people is not in Maryland's best interest.
House Minority Leader Anthony J. O'Donnell said the cost to implement reform in Maryland will be "staggering," especially once federal subsidies shrink as scheduled under the law. The Republican, who represents Calvert and St. Mary's counties in the General Assembly, said raising taxes would be the only way to pay for it and believes Congress should move to repeal the law.
Maryland Attorney General
bemoaned that the law had become political fodder instead of a discussion about health care.
He wrote a "friend of the court" brief on behalf of several states that supported the law, arguing that Congress had the right to mandate that Americans buy health insurance as a means of regulating the economy under the Constitution's Commerce Clause. The court narrowly disagreed with that argument but upheld lawmakers' ability to require Americans buy health insurance under its taxing authority.
The outcome for consumers was no different, he said. "The bottom line is the Supreme Court found the Affordable Care Act is constitutional," he said. "There will be a dramatic increase in the number of Marylanders with insurance."
Other groups were split on the court decision and on the impact of the law, which aimed to cover more people and cut costs.
supported it, the state medical society MedChi opposed the measure. MedChi CEO Gene M. Ransom III said that while his group supports expanded health coverage, the reform didn't go far enough in addressing cost concerns, including threatened cuts to Medicare payments to doctors and malpractice liability.
Carmela Coyle, president and CEO of the Maryland Hospital Association, agreed that even more needs to be done to address growing medical costs and said the Obama bill isn't perfect. But her group supported reform and said that the court's health care decision will allow the state to continue to increase coverage for its residents.
"I think the Supreme Court decision replaces a lot of negative what-ifs with a single positive, and that is to change for the better the way we take care of people in the United States," said Coyle, whose organization represents 46 acute-care hospitals. "That is what
was all about."
Insurers also said more needs to be done to identify methods of improving care and cutting costs.
"Health care modernization did not begin and must not end with the enactment of the Patient Protection and Affordable Care Act," UnitedHealthcare said a statement. The company "strongly supports making high-quality health care accessible and affordable for everyone. Now is the time to apply proven ideas and best practices to build a better health care system."
A spokesman for
, the state's largest health insurer, which supported the law, said the insurer would work with officials on implementation.
For their part, consumers are also split on whether the law is flawed. Many who have chosen not to buy insurance in the past will likely oppose it, said Douglas Hough, an associate professor in Johns Hopkins' Carey Business School.
A large number of Americans work part-time or two jobs that don't offer coverage, and they decided they couldn't afford a policy or they were healthy enough to go without, Hough said. But the behavioral economist said he believes most people will now buy coverage.
"The penalty for not buying insurance is not onerous, but since it's called a 'mandate,' people will buy insurance," he predicted. "That's a good thing because essentially it's the only way this will work, if the low-risk and high-risk people are included in the pool. … And most people buy insurance knowing they'll really have to use that insurance because pretty much everybody uses health care."
If an estimated 32 million additional people are insured through the law, that would put the United States more in league with other rich countries in terms of population covered, said
, professor of bioethics and public policy at the
But he said Americans still haven't addressed the fundamental question answered in those other countries about whether health care is a "moral imperative." Rather, he said, it is viewed as more of a political and economic question. In contrast, he said, Americans have decided as a society that they want free education for all, health care for seniors and Social Security.
"This is a really significant moment in American health policy," he said. "But it remains to be seen if health care for all is embraced like the others."