WASHINGTON — The Patient Protection and Affordable Care Act of 2010 emerged from a Supreme Court review constitutionally intact and with most of the law's tools to expand health coverage to more than 30 million Americans still available.
A majority of the justices concluded that while Congress can't make it a crime for people not to buy health insurance, it can impose a penalty, or "shared responsibility payment," on those people Congress can tax.
With that central tenet of the law upheld, the court also left in place almost all the other provisions, except for another penalty clause: the threat that states that don't expand their Medicaid programs to insure people well over the poverty line stand to lose money they already get from the federal government.
Florida Gov. Rick Scott said the state will not comply with the new law.
The ruling unveiled Thursday is shaking the political landscape and launching new lobbying efforts to tweak the law or rules for implementing it. Republicans in Congress are ramping up efforts to repeal the law this year or next year. And more lawsuits against some of its provisions, such as requiring coverage for contraception, still will occupy the courts.
But for now, the national health-care reform clock ticks on toward 2014, when the law is slated be fully implemented. Here, in question-and-answer format, are some of the implications:
Q. What does this mean for the average American family's health coverage?
A. For individuals and families, it means they will remain covered through health plans sponsored by employers, which now cover just less than 60 percent of Americans. Recent surveys suggest that most employers that offer insurance will continue to do so, and by 2014, when the health law takes full effect, 86 percent say they will offer it.
People who get their insurance as individuals in the "individual" insurance markets will still have to wait until January 2014 to shop in new state health exchanges, but may get some early benefit from other insurance market reforms.
Q. What about the subsidies and other incentives for companies to offer insurance to employees, and the fines if they don't?
A. Those provisions will continue as planned. Small-business tax credits that have been available since 2010 will continue for eligible firms, and penalties against firms with at least 50 full-time employees whose workers get a subsidy from the government to help pay their premiums all stay in place
Q. What happens to the expansion of Medicaid coverage?
A. This could be the biggest impact of the decision. By expanding Medicaid coverage to adults with incomes up to 133 percent of poverty ($18,310 for a family of three in 2009), the law is expected to cover as many as 17 million more Americans.
Although the court says the government can't dock a state's existing Medicaid payments for not expanding coverage, the ruling allows the feds to offer to pay, first, 100 percent, and later, 90 percent of the cost of the expansion between 2014 and 2020 and beyond. So while it's expected that many states will take part in the new program, some will opt out.
Q. What will happen with the health-insurance exchanges the law requires every state to have, although only about a dozen have set them up so far?
A. Only 15 states have not accepted federal grants to establish the new insurance marketplaces, and even some of them have made some plans on their own. The arrangements are supposed to be in place by November and federal money to set up the exchanges expires in 2015. While a few Republican governors may still balk, most jurisdictions are expected to have the exchanges ready for business by 2014. The exchanges are expected to provide access to coverage for up to 20 million Americans who lack it now.
Q. Does the ruling change any of the law's restrictions on private health insurance plans that are already in place?
A. No. Many advocates had worried that if the court struck down the mandate to buy insurance, the law's market reforms would also be dropped. But some major insurers already had pledged before Thursday to keep some of the more popular provisions no matter what the court decided. With the law upheld, all those restrictions will remain: Insurers will not be able to drop you because you get sick, refuse insurance to children because of pre-existing conditions, or impose a lifetime maximum on the amount of your benefits. Insurers will also have to spend 80 percent to 85 percent of the premiums they collect on medical care, and they must allow parents to continue coverage for adult children up to age 26 if the children can't get insurance on their own.
Q. What about the changes to Medicare required by the law?
A. They will all stay put. Discount prescriptions for seniors and disabled people who get a reimbursement for the extra costs they must pay because of the so-called "donut hole" of Medicare coverage will continue. And the newly covered preventive care