So I guess the chickens have finally come home to roost, or have they?

The historic decision that was passed to a nation holding its collective breath at 10:10 a.m. EST on June 28 was likely one of the most momentous ones in the history of the country. But does the decision bring with it the aura of finality that is so typically associated with decisions of this magnitude? Does it bring with it the same collective focus on the tasks ahead that the declaration of war on December 8, 1941, brought to the American war effort?

I don’t think so.

Round one is done and dusted, but there are a few more likely to come. Look no further than the contrasting voices emerging from the two camps -- one hailing it as a great triumph of American jurisprudence, and the other as a war cry for a change come November. Whether the Republican Party will have enough votes to overturn the law, provided they win the presidential race, is anybody’s guess. But the punches-counter punches are not going away anytime soon.

The ruling left choices for the states that will lead to the continuation of political divide. For example, the ability for states to opt out of Medicaid expansion without any loss of federal aid for their existing Medicaid programs leads to a huge policy decision for the states.

Let’s talk about the other centerpiece of the law, namely the insurance exchanges. Until now, more than two-thirds of the states had not started the implementation phase of the exchanges (post-planning work that is). They were sitting on the fence waiting for the ruling to come down. Now what? The ruling is here, and until something else happens, the exchanges are here to stay. The date is still January 1, 2014, (effectively, October 1, 2013, considering the open enrollment period). That is less than a year and a half away. So, with such a short window, are we counting on the date to shift? Who knows, but short of that, states have a lot to do.

To begin with, states have to decide on their implementation structure. Do they want to go with the federal exchange? Do they want to fast track an RFP? Do they want a cloud offering, which could offer less flexibility? Each of these options comes with highly varying price tags and degrees of control. In addition, each state needs to make functionality scope decisions—does it integrate exchanges with other public welfare programs so that it is a truly integrated no-closed-door operation, or does the state just implement a new exchange platform along with existing systems, simply integrating them through data exchange?

Decisions are many; time is short. I hope these decisions don’t get swayed by political affiliations, but are made on a prudent basis, considering the best of those who actually need the support.

On a slightly tangential note: The whole ruling process, wherein the Chief Justice went beyond the party lines in deference to the interpretation of the Constitution to make an unprecedented decision, simply renewed my belief in the greatness of the American judicial system. Bravo. The band still plays on.


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