The Supreme Court has ruled on the Affordable Care Act. (afagen/Flickr)

Update 6:42 PM Interview with Nancy Pelosi on Health Care: It was always in the bag

KQED’s Jon Brooks posted a full transcript, audio and some commentary (always fun) about Scott Shafer’s interview with Nancy Pelosi. It’s a great overview of the drama surrounding the Act over the years.

Update 1:47 PM Supreme Court Ruling Could Be Good for the State’s Budget

The LA Times is reporting that “California stands to receive as much as $15 billion a year to extend coverage to millions of the poor and uninsured starting in 2014.” Welcome news after last night which saw Governor Jerry Brown whittling almost $200 million more from the budget before finally approving it.

Update 12:24 PM Open Browser, Insert Foot

KQED’s News Fix blog has a great post up about all the tweets flying around after the decision. Some ill advised ones from public officials. And a slew from disgruntled Americans who don’t like the health care plan announcing they’re “moving to Canada.” Hmmmm.

Update 11:43 AM “The Horse Is Out Of the Barn”

The head of California’s Health Benefit Exchange, Peter Lee, just spoke. He’s been leading California’s efforts to create an online market for health insurance. He long contended it would move ahead regardless, but the mandate for all to have insurance definitely ups its relevance. Lee said his goal was to make an online system that would make buying health insurance as simple as buying a book from Amazon (or almost as simple). He also detailed what this decision means for Californians pocketbooks (or purses as we say in California). Lee also said “the horse is out of the barn,” and unlike what some commentators are saying he believes the Affordable Care Act is here to stay.

Update 10:23 AM Take It Online:

As if to underscore the contentiousness that President Obama was referring to, Chief Justice Robert’s Wikipedia page was just vandalized, according to Talking Points Memo. Apparently the caption under his photo was changed to “17th Chief Traitor of the United States”

Update 9:23 AM: President Obama Addresses the Nation

The President spoke to some of the benefits of the law. And referring to the contentious debate Obama said it should be clear by now I didn’t do this because of political reasons.

Stay tuned for more reactions to the decision from within California.

Update 8:24 AM: President Obama scheduled to address the nation at 9:15

Update 8:10 AM: Impacts of the decision for California

The decision holds some good news for the state, although there are those that say – especially in the immediate wake of another painful budget process – it’s going to mean too much spending, with not enough gained.

California Healthline lays out the nitty gritty in this article. But here’s a quick overview from the piece.

On the positive side, some predict it would create 100,000 jobs in the Golden State and others point out that California has long been in the lead in enacting many of the reforms, so we’re already well on our way. The article says Peter Long from the Blue Shield of California Foundation and MIT economist Jonathan Gruber last year modeled the ACA’s impact on the Golden State.

According to their predictive model, the law by 2016 would:

• More than halve the number of the state’s uninsured, from 6.53 million to 3.10 million;
• Reduce employers’ health insurance spending by 6%; and
• Add about $280 in average economic benefits to each household.

Sounds good. But critics say that the additional costs could actually lead to job losses. Voices of concern come from the left and the right. Former US Labor Secretary Robert Reich, an icon of the left, felt the best chance the country had for real health reform was if the law got struck down.

Meanwhile some on the right fear it will lead to too much hiring in state and county government.

The article goes out on this cheery, are we all just spinning our wheels question: would the ACA just get overturned by a Republican president anyway?

The decision is posted here. All 193 pages. A big one. Justices clearly had a lot to say.

Update 7:33 AM: The tax reading carries the day

Here’s an article from the Los Angeles Times explaining the intricacies of the tax argument.

Update, 7:27 AM:  Nuances from the individual justices

Now from scotusblog.com: Kennedy is reading a dissent saying the whole thing should be invalid. Meanwhile Ginsberg writes it should be entirely valid. “Justice Ginsburg makes clear that the vote is 5-4 on sustaining the mandate as a form of tax. Her opinion, for herself and Sotomayor, Breyer and Kagan, joins the key section of Roberts opinion on that point. She would go further and uphold the mandate under the Commerce Clause, which Roberts wouldn’t. Her opinion on Commerce does not control.”

Update 7:14 AM: Chief Roberts’ vote saves ACA

(AP) WASHINGTON (AP) – The Supreme Court on Thursday upheld the individual insurance requirement at the heart of President Barack Obama’s health care overhaul.

The decision handed Obama a campaign-season victory in rejecting arguments that Congress went too far in requiring most Americans to have health insurance or pay a penalty.

Chief Justice John Roberts announced the court’s judgment that allows the law to go forward with its aim of covering more than 30 million uninsured Americans.
Update, 7:12 AM: Scotusblog reports: So the mandate is constitutional. Chief Justice Roberts joins the left of the Court. The Medicaid provision is limited but not invalidated.

Scotusblog reports: The individual mandate survives as a tax.

MARTIN How do you feel that Chief Justice Roberts, a fellow conservative, voted to uphold the law?

SUNDHEIM Well I think he really had a lot of things he was trying to address. One was the specific issue of the mandate and the commerce clause. That’s why I think so many people thought the legislation would be overturned. And the fact he was able to make a bridge to find that it was a tax, not a mandate.  I think was very interesting.

I thought the reasoning was a little tortured but I think he was really concerned about the future of the court, the public perception of the court.

So I understand what he was trying to do. Again it’s not a situation where they’re making a decision that ties the hands of the other branches of government. It really transfers to the decision to those two branches. And it’s now up to those two branches to make a decision that’s in the best interest of the people.

MARTIN The Bay Area is a favorite stop for presidential candidates from both sides of the aisle because of deep pocketed residents. How do you think it’s playing out among local Romney supporters?

SUNDHEIM I haven’t had a chance to talk with too many today. I think what’s going to be interesting is really what it comes down to now. And the court has made it perfectly clear today what their view is. This is a substantial tax increase on many people, on many different points of the economic spectrum. And the question is whether that is going to be a problem for the president, who promised that there would not be a tax increase and that in fact this legislation was not a tax increase.

The supreme court has said the president was wrong, that it is a tax and it’s a very substantial tax. So that will be an issue that the people will have to decide. Is this a tax increase that they approve or do they want to overturn it?

MARTIN And among California Republicans do you have a sense how that will play out?

SUNDHEIM I think clearly there will be opposition, but the opposition to the legislation existed prior to today. I think some people will be more motivated because of the decision of the court, and how it is important that if they do not want the tax increase that we need to elect leaders that oppose this kind of tax increase.

A sign from a recent health care rally (seiuhealthcare775nw/Flickr)

Health disparities in the state are stark.

“Diabetes affects 13 percent of Native Americans in the state, 11 percent of Latinos, 10 percent of African Americans,” says Ellen Wu, the executive director of the California Pan-Ethnic Health Network (CPEHN). “That’s compared to five percent of the white population.”

Wu says there’s a gap in access to care too. That’s why the Supreme Court decision upholding the Affordable Care Act is such a watershed moment for her.

She says of the three million Californians who will now be eligible for coverage through the state’s health benefit exchange in 2014, two-thirds come from communities of color.

“For example with diabetes … they’ll be able to get screened earlier and prevent it. And when they do have onset they’ll be able to manage their care better and stay healthier,” said Wu.

The same goes for asthma, she said. “We know that for communities of color, they can show up in the emergency room for an asthma attack at higher rates than whites so the free preventive care under the Affordable Care Act (ACA) is really, really critical to keeping our communities healthy.”

The news of the decision was especially welcomed among the state’s Indian tribes. It turns out that folded into the ACA was a provision updating and making permanent a 1976 law on health care for American Indians and Alaska Natives.

Indians leaders had been working for fourteen years to get the law – called the Indian Health Care Improvement Act – reauthorized, and some people wanted it approved as a stand alone legislation.

Some of the updated provisions include giving authorization for hospice and assisted living care and establishing comprehensive behavioral health prevention, and treatment.

In response to the decision James Crouch, the executive director of the California Rural Indian Health Board, said it gives them confidence in their “efforts to establish a Low Income Health Program for our tribal communities and ensure successful implementation of some of the key improvements to the Indian Health Care Improvement Act.”

For many advocates, today was decades in the making.

Remember Health Reform efforts, Act I? Ellen Wu says CPEHN was founded in the 1990′s back when the Clinton administration was working on the issue.

“To see it 20 years later be able to… to come to fruition, is really an amazing experience.”

Wu got choked up. “It’s the biggest thing that happened since the 60s, with Medicaid and Medicare and we get to be a part of it. it’s really exciting.”

The California Health Benefit Exchangeis the most tangible institution that Californians will interact with as a result of the law. Those newly in the market to buy insurance because of ACA, this is your go to shop.  Officials estimate that’s around 3 million Californians.

“We look forward to making the purchase of insurance through California’s exchange as easy as buying a book on Amazon or shoes on Zappos,” says Peter Lee, who has been working to set up this online marketplace.

Lee spoke right after the decision and one of the first questions he fielded was what income levels will qualify for insurance subsidies and how big the credits will be.

I’ve pasted in a chart his office released below to give an overview of the amounts. The credits go to those earning up to 400% of the federal povery level (FPL). So if you’re, say, a family of four earning up to $93,000 you qualify for help buying insurance.

Health Benefit Exchange income levels and credits (source: http://www.healthexchange.ca.gov/)

Lee also outlined the next steps for the Exchange. It’s been in the works for two years now, which puts California ahead of other states on this issue. But there are three areas they’ll focus on now:

1. Working with health plans to hammer out details of the insurance they’ll offer.

2. Launching a big education campaign in 2013. Lee says there’s been a lot of “misinformation” out there and the right info needs to get into the hands of the uninsured.

3. Setting up the IT system needed to power the system.

Where is the money coming from to fund all these efforts? Lee says right now the Exchange is backed by money from the federal government (they just applied last night for another $196 million grant), but after the first full year of the Health Exchange it will be funding itself from the health care plans it works with.

A word bubble displays the most prevalent words in Democratic reactions to the Supreme Court's ruling on the Affordable Care Act.

Responses from California Politicians are starting to roll in.

Here at State of Health we made wordles out of the statements from the Democrats and the Republicans. Can you match the word cloud to the party?

A word bubble demonstrating the most used words used by Republicans in response to the Supreme Court ruling.

A hint: reading through the statements, themes from the Democrats: “great day,” “reaffirms what is right,” “benefits millions.” Themes from the Republicans: “great harm,” “repeal,” “take back the White House.” The Sacramento Bee has a wide round up. Here’s a sampling:

Democratic U.S. Sen Barbara Boxer

The decision is great news for the millions of Californians who have already seen the benefits of this law – including the six million who now have access to free preventive health services, 355,000 young adults who now have coverage on their parents’ health plans and 320,000 seniors who have received help in paying for their prescription drugs. … We will continue to fight Republican efforts to repeal these important health benefits while we work to make sure every American has access to quality, affordable health care.

Democratic U.S. Sen Dianne Feinstein

This is an historic day. The Supreme Court today upheld the health care reform law passed by Congress in 2010, meaning Californians can be confident that access to affordable health insurance is finally a reality. …

I realize that passage of health care reform was extremely controversial. But we cannot forget that insuring fellow Americans and driving down the exploding cost of health care spending in this country is a national emergency. Even with this favorable decision from the court, our work reforming the insurance market and expanding access to health care continues.

Rep. Darrell Issa, R-Vista

The Supreme Court has ruled to uphold the President’s Obamacare. Despite being viewed as Constitutional by a narrow majority, this law will do great harm to our country by imposing new taxes, burying job creators in new red tape and saddling future generations with debt they can’t afford.

In selling Obamacare, Congressional Democrats and President Obama assured the American people that it was not a tax. Today, the Supreme Court ruled it was, in fact, a tax. This tax was imposed on the American people amidst an extended recession and is one of the many reasons our economy remains stagnant under President Obama’s leadership.

To date, the Republican-led House of Representatives has voted 30 times to repeal, dismantle and defund Obamacare–and we will continue our efforts to repeal this law and replace it with health care reform that enacts needed reforms without imposing costs that will be paid by subsequent generations.

“In the days ahead, I will work with my colleagues to achieve real solutions to America’s health care challenges that do not infringe on doctor patient relationships, impose unpopular mandates, and do not add to the nation’s already significant debt.”

Elizabeth Emken, Republican U.S. Senate nominee

The high court’s decision makes it crystal clear that the only way to ensure that Americans repeal this dishonest attempt at health care reform is to take back the White House and the U.S. Senate this November.

Democrats like Dianne Feinstein lied about the cost of Obamacare, then stole from Medicare to justify the initial price tag. Now they are attempting to steal from core institutional programs at the Centers for Disease Control that support programs for the disabled to cover up the ballooning cost. That’s not just shady politics, it’s just plain wrong. And now the Supreme Court ruling has brought Obamacare’s hidden taxes to the light of day.

Obamacare will continue to have a negative impact on job creation and hiring, and businesses will be forced to continue to grapple with all of the uncertainty and costs the law creates. The simple truth is that businesses across the nation are not hiring as a result of this administration’s mismanagement of health care reform.

Only with new leadership in Washington can we expand access and lower costs through competition and choice while keeping in mind our responsibility to care for the truly vulnerable without raising taxes or increasing debt. I will vote to repeal the Obamacare tax dragging down our economy and hurting families. Dianne Feinstein won’t. It’s a simple choice.

ACA Supreme Court Health Care Decision

Someone asked the moderators there why healthcare is being decided on the last day of the term. The answer:

For one thing, it was only argued in late March and it often takes several months to write opinions in complicated cases. In addition, in big cases where there are multiple opinions, it takes a while for the dissents and concurrences to get written. Finally, the Justices often just take as much time as is available to polish their opinions in big cases.

For more on the possible implications for California see this excellent post by KQED’s Jon Brooks and Mina Kim.

Supreme court rules in the Affordable Care Act decision (photo: s_falkow/Flickr)

This morning came and went without a health care decision. One of the experienced lawyers following the proceedings was asked when a decision had ever been so anticipated:

I am pretty sure that the answer … is NEVER. In Bush v. Gore, it all moved so quickly and we didn’t know when we would get a decision.

Barring a highly unusual deferral until the next term, the final health care decision will come out on Thursday morning around 7:00 AM pacific time.

Like all controversial issues this one goes by many names. The law under consideration started life as the “Patient Protection and Affordable Care Act” but was nicknamed “Obamacare” by Republicans. Now some Democrats are trying to reclaim “Obamacare” for their own.

There’s not just a lot of jockeying about the name. The complex legal intricacies have inspired plenty of explainers and Q&A’s around the web today. Here are some of the highlights.

The L.A. Times ran a piece that looked specifically at the legal issues at stake and why the Court could consider this as a tax law case, throwing a wrench in things.

The Washington Post has a blog post aptly titled “Everything you need to know about Obamacare and SCOTUS in one post.”

But if that’s not enough, here’s this consumer guide from Kaiser Health News.