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After the ruling: Lots left to do on health care reform

By Maggie Fox

The Supreme Court upheld President Barack Obama’s health reform law on Thursday, with conservative Chief Justice John Roberts making up the surprise swing vote and writing out a road map for making the law work.

It is of course a big victory for the Obama administration. But it’s not the end of the story, not by a long shot. Even if everything goes smoothly, many important provisions don’t go into effect until 2014 and later. And Republicans, from presidential hopeful Mitt Romney through to members of Congress and governors of close to half the states, renewed their promised on Thursday to fight tooth and nail to either repeal the law or at least chip away at it.

"Today's decision makes one thing clear: Congress must act to repeal this misguided law,” Senate Minority Leader Mitch McConnell, a Kentucky Republican, said Thursday.

More than half the states have been gambling that the law would be struck down and have done little or nothing to put into effect one of the law’s main provisions – the exchanges, where people are supposed to be able to go online and get enough good information to choose a health insurance policy. They’re scheduled to be up and running by 2014. The Health and Human Services Department says 34 states have taken money to set up exchanges.

And HHS hasn’t finished making all the rules clear for how to put the full law into effect, and doesn’t have all the money and staff it needs to do that work. The November elections will be very important for determining whether Congress helps or hinders this effort.

Plenty of provisions look set to move ahead. They include changes meant to make doctors provide more effective care. Starting in 2015, doctors will get paid for keeping patients well, not necessarily for every test or procedure. That means, in theory, that a doctor will get paid the same by Medicare or Medicaid whether she gets a patient’s blood pressure down by prescribing drugs or by persuading him to lose weight and exercise.

Accountable Care Organizations will also continue to be created. These new organizations are meant to encourage cooperation by grouping independent care providers such as doctors with hospitals. And the trend toward consolidation is likely to continue no matter what happens with the health reform law – something that, in theory, will make it easier to connect patients with specialists, for instance.

Rules that stop insurers from what the government considers abusive practices also stay in place. “Insurance companies can no longer impose lifetime limits on the amount of care you receive. They can no longer discriminate against children with preexisting conditions,” Obama said in Thursday in response to the ruling. “They can no longer drop your coverage if you get sick. They can no longer jack up your premiums without reason. They are required to provide free preventive care like check-ups and mammograms -- a provision that's already helped 54 million Americans with private insurance,” Obama added.

“And by this August, nearly 13 million of you will receive a rebate from your insurance company because it spent too much on things like administrative costs and CEO bonuses, and not enough on your health care.” The Health and Human Services Department checks insurance plans to make sure they spend at least 80 percent of premiums on direct health care.

Small businesses will still get tax credits to help pay for health insurance for workers and people who retired at age 55 can get special insurance to hold them until they turn 65 and become eligible for Medicare.

Poll: Do you agree with the Supreme Court ruling on health care?

The controversial requirement that insurers and employers pay for all contraceptive care free of charge to women will also stand.

One group has an uncertain future – poor people without children. The Supreme Court ruling struck down the requirement that states expand Medicaid to about 16 million people who make less than 133 percent of the federal poverty level, or about $30,700 for a family of four. Many states currently offer Medicaid mostly to pregnant women and children, but poor adults are often not eligible. The health care law did require states to broaden that and the federal government was going to pay for almost all of it starting in 2014 and would pay more than 90 percent through 2022.

The ruling says states can’t be forced to do this, and now it’s not clear which states might decide not to.

 More on health care ruling:

Supreme Court upholds health care law

Thrilled and relieved, sick patients cheer court ruling

Health reform is legal, but is it moral? Bioethicist weighs in

President Obama tells the nation in a televised address that the Supreme Court's ruling on the Affordable Care Act "reaffirmed a fundamental principle" that "no illness or accident should lead to any family's financial ruin."