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

The decision by the Supreme Court to uphold the constitutionality of nearly all of President Barack Obama’s health reform plan is ethically very good news. Excluding tens of millions of Americans who had no access to health insurance because they could not afford it or because no one would insure them because they were too sick has long been the single greatest ethical failure of American health care.

The Supreme Court has now affirmed, admittedly on purely legal grounds, that imposing a mandate on each of us to pay for health insurance for all of us can happen. But Obama and the administration cannot become complacent. They still have a huge challenge before them — selling the American people on the morality of insuring access to every American to health care by mandating that we all pay.

Critics of the Affordable Care Act have convinced America that the Obama plan stinks. The government mandate was their best bogeyman in stirring distrust of health reform. They had placed all their chips on a "shock and awe" strategy of having the Supreme Court blow away Obamacare’s mandate in one gigantic negative decision. That did not happen. 

The critics will now shift gears and start to fight a guerilla war to chip away at the plan. They will complain about cost, government meddling in the doctor-patient relationship and reopen talk of death panels. The only way to meet these criticisms is for the administration and its allies to do what they still have not done — convince the American people, not of the legality of health reform as happened today but of its morality.

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

The moral case involves three key arguments. First every American deserves equality of opportunity.  The only way to ensure that is to ensure access to basic health care. Just as is true of food and education, you need access to basic health care to compete and flourish in a free market.

Second, no one should go without health care just because they are sick. Excluding people because of pre-existing medical problems is simply immoral.

And lastly if we are a truly a nation, then we have to act like one and bring everyone into access to basic health care by all being willing to pay something for it. Individual rights dominate our political rhetoric. What we need to hear from the President is more about our duties and obligations as citizens to one another.

The Supreme Court has now deemed health reform legal. It is now up to the president to make sure that Americans buy into the argument that it is moral.

Related news:

Supreme Court upholds health care law

Thrilled and relieved, sick patients cheer ruling

By Joan Raymond

The Supreme Court is expected to deliver its ruling on the validity of the individual mandate requiring nearly all Americans to buy insurance or face a penalty-- and perhaps the validity of the entire reform package -- in June.

Two years ago when the most sweeping legislation regarding health care was first enacted, msnbc.com talked to numerous people about their health care needs, and their hopes or fears regarding health care reform. We wanted to know if the people we spoke with back in 2010 had changed their minds about healthcare reform, due perhaps, to changes in personal circumstances. Here is an update on some of the people we interviewed. 

Readers reveal real-world impact of health reform

Billy Weeks / for msnbc.com

Aubree Sullivan Carpenter

Name: Aubree Carpenter (formerly Sullivan), 28, Chattanooga, Tenn.

Occupation: Education director, Epilepsy Foundation, Southeast Tennessee

Income: $29,500 annually

Current insurance: Blue Cross Blue Shield personal plan, excludes coverage for melanoma 

When she was 19, Carpenter was diagnosed with melanoma, the most serious, potentially deadly, form of skin cancer. Surgery was successful, but getting insurance with a pre-existing condition was tough. When she went to work full-time at the local chapter of the Epilepsy Foundation, she still had trouble qualifying for insurance, but found a plan that would cover everything, except her melanoma. Her situation is still the same today.

Although she’s now happily married, her husband, Keelan, is a full-time college student studying computer science and doesn’t have a group health insurance plan. Her employer does pay for her plan, which costs $330 a month, and for that she is very grateful.

Today, Carpenter is healthy. But she has concerns. “It always crosses my mind that I might get another lesion,” she says. “I don’t know what I would do. It can be worrisome, but you have to do what you have to do.”

She is somewhat confused about the individual mandate, but feels that health care reform must happen, especially for those with pre-existing conditions. “I appreciate what President Obama has done to move the conversation forward,” she says. “Insurance companies shouldn’t be able to discriminate or drop you. But I don’t know if a mandate is the answer. There are a lot of questions.”

What she would like to see is the government offer competition to the private sector insurers that would provide competition at affordable rates for people.  “Fed Ex and UPS are competition for the postal service, and I would like to see something similar for health care, that doesn’t discriminate against those with pre-existing conditions, and the self-employed or those, like me, who work for small organizations,” she says. “Because I’m not in a group plan, I have no options.” 

Her only recourse, she says, would be to change jobs and find an employer with a group plan, which would hopefully take her.

She does not want to see the entire reform package get dismantled. “I don’t want them to repeal the whole thing,” she says. “There are thousands of people with more tragic stories than mine. I would be sad for them I am afraid that things will go back to status quo and nothing would ever be done.”

Charles Mason / for msnbc.com

Robb Myers
Fairbanks, Alaska

Name: Robb Myers, 28, Fairbanks, Alaska

Occupation: Truck driver

Income: $45,000 annually

Current insurance: Employer-sponsored Plan

Back in January 2010, Myers was a single guy who lived in a modest apartment, drove a 2000 Hyundai and tried to keep his living expenses as low as possible. He turned down health insurance coverage because he was young and healthy.

Today, Myers, now 28, is married and lives in a slightly larger apartment in Fairbanks, but still drives the same car, he and his wife, Dawna, share. The couple is expecting their first child in the middle of May. Myers now works as a full-time truck driver. His wife is a part-time nanny. Myers now carries health insurance, which costs $460 a month. When their child is born, the premium, he says, will double. They also carry a high deductible of $3,000, but his employer runs a program in which costs over $1,000 are reimbursed until the deductible is reached.  

Myers, a “news junkie”, has been following the hearings. “I think the individual mandate is a stupid idea,” he says. “Ultimately, responsibility needs to fall on the individual person and not the government telling us what we need to buy. I know what I need to buy and what I can afford to buy.”

He believes that the government is on the “wrong track” with healthcare changes. “It’s going to be an economic issue, and they took a look at the demand side, not the supply side.” To cut costs, he’d like it to be less expensive to study medicine and become a doctor, and to have other medical professionals, such as nurses, “. . . do some of the things,” that traditionally fall under the purview of a doctor.

“Today, my situation has changed but I don’t see that the healthcare law is really helping much,” says Meyers, who has been with his new company since June 2011. 

His colleagues have told him that insurance coverage used to be more encompassing, but after the Affordable Care Act passed, premiums actually rose. “It makes me wonder, if something in the bill kicked up the premiums,” he says.

He does believe there is “a social dimension,” to the entire issue, to be, in a sense, “. . .our brother’s keeper.”

He mentions friends who used Facebook to fundraise for monthly pledges to help offset costs for their daughter’s residential treatment program, which is out of state. Within a week, they had more than half the money needed to cover the $40,000 charge insurance would not cover. “We have a have a responsibility to each other, and having the government do it for us isn’t fulfilling that responsibility,” he says.

John Makely / msnbc.com

Greg Mohr and his wife Susan in Randolph, NJ, Jan. 4, 2010.

Name: Greg Mohr, 49; Susan Mohr, 43, Randolph, N.J.

Occupation: Self-employed computer technician, owner of cat kennel

Income (household): $92,000 annually

Current insurance: Small group HMO

Greg Mohr still runs his New Jersey computer network business and with his wife, Susan, a cat kennel owner. Mohr remains opposed to the health care overhaul and is vehemently opposed to the individual mandate. “My personal hope is that they (the Supreme Court) rule it (the individual mandate) unconstitutional and illegal,” says Mohr, who does believe, however, that health care does need to be changed.

Today, Mohr, whose income has stayed the same as it was two years ago, is paying significantly more for health insurance. The rub: He’s paying more for less coverage. Back in 2010, Mohr’s plan, which covered him, as well as his wife and two children, cost $14,640 a year. Today, he’s paying $16,500 a year, under a new policy, with higher co-pays and a few more restrictions. He recently talked to his broker and is bracing himself for a significant increase when he renews his policy in October.  “It turns my stomach,” says Mohr, who estimates that 10 years ago his health insurance ate up only about 5 percent of his income. “If I raised my rates like this I would be out of business, but the insurance companies have an attitude that they want to get as much as they can.” 

Instead of the current plan, some of the changes Mohr would like to see include liability limits, deterrence of nuisance lawsuits, as well as an elimination of cost differentials in procedures depending on where you live. He would also like to see hospitals and health insurers become not-for-profit entities.  “I can sympathize with both sides, but in our interest it would be best for us to have the entire (health reform) package overturned and go back to the drawing board,” he says. “Not enough time was spent truly looking at options.”

Allen Brisson-smith / for msnbc.com

Ed and Sharon Blanding of Danbury, Wisconsin, at their home on Thusday, April 8, 2009. Photo/ Allen Brisson-Smith

Name: Sharon Blanding, 67; Ed Blanding, 63, Danbury, Wis.

Occupation: Retired

Household income: $45,000

Current insurance: Traditional Medicare, plus Part D for prescription drugs and a supplemental policy

With Sharon retired and having chronic medical problems, and with her husband Ed, on disability with his own set of chronic health issues, the past two years have been a little tough for the couple, both economically and physically.

Sharon takes 14 medications, up from nine. Ed, she says, now takes six prescription drugs, instead of four. They have a retirement income, but the costs of health care are “staggering,” Sharon says. They pay about $600 for a Part D Medicare supplement and supplemental health insurance coverage. Their prescriptions can run more than $250 every month. Last year, Sharon came in just a few dollars short of hitting the magic number of $4,000 to reach a point in which “catastrophic” coverage would kick in after paying out-of-pocket costs.

Reform did help the Blandings a little, focusing on the so-called “doughnut hole,” a gap in Medicare's prescription drug coverage until an individual hits certain thresholds. Under reform, the Blandings each received a check for $250. “It was nice, and it did help us, but not really a lot,” says Sharon.

Because of the economy and their health conditions, the Blandings have been trying to sell their Wisconsin property for the last year and move to a warmer, drier climate. “If it doesn’t sell, though I think it will eventually, we’ll be in bigger trouble,” she says.

She does not want to see the individual mandate or healthcare reform overturned. “Ditching the individual mandate would be bad, but ditching the entire package would be horrible,” she says. “Every year it would get better for us and people like us, and if they take it away they take away a lot of help, a lot of hope.”

But she says her sense of “dread,” may have a bright side. “Maybe that will be good and maybe we’ll go to a single payer system, which is what we should have done in the first place,” she says.

She says that in her all her years she has never been so disgusted with politics. “We’ve done everything right all of our lives, but people need to understand, almost everyone will get sick and even with insurance, it can be horrible,” she says. “There is a horrible mindset among the right wing that I think they would do absolutely anything to get rid of President Obama and his policies. I truly hope the Supreme Court sides with the law, rather than their politics.”

Related:

Court signals entire health care law might need to be struck down

Justices express skepticism over constitutionality of health care mandate