June 29--State Sen. Tom Courtney, D-Burlington, was shocked and dumbfounded to see the U.S. Supreme Court uphold much of the Patient Protection and Affordable Care Act. But mostly, he was happy.

"To me, it's going to be as life-changing in America as Social Security was," Courtney said on Thursday afternoon reacting to the Supreme Court decision. "I'm happy about it."

But with the law upheld, it means the state Legislature likely will have much work to do in the next two years to meet the deadlines Congress imposed for fully enacting the PPACA by 2014.

Among the areas where state legislatures will have some role to play is in establishing the health insurance exchanges, where those without insurance can shop for care, and setting up a process for expanding Medicaid.

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According to U.S. Sen. Charles Grassley's office, there are about 60,000 to 70,000 Iowans who will be newly eligible under the Medicaid expansion.

While Courtney is confident the court's decision means the process will move ahead at the state level, state Rep. Dave Heaton, R-Mount Pleasant, is waiting to see the results of the November presidential election.

"I don't know what we've got to work with until after the election. And when we see what the makeup of Congress is going to be, and who the president is going to be, then I guess we can react and start to make decisions from there," Heaton said. "At the present time, I think everything is kind of still the way it was."

While Courtney didn't make any predictions about the future for the Democratic President Barack Obama, he said the fact the law was upheld vindicates the president. He also is disappointed to hear that presumptive Republican nominee Mitt Romney would repeal the law and remains unsure of what would replace the current law.

"I think their Achilles Heel is that they don't have an alternative. If they have something that was a real good alternative, it would be a different story, but they don't," Courtney said.

Like Courtney, Heaton was surprised by the decision, and Chief Justice John Roberts was the swing vote in the 5-4 majority to uphold much of the law. Heaton also was surprised the mandate was upheld as a tax, rather than a penalty.

Heaton, who is chairman of the Health and Human Services Appropriations Subcommittee, said despite the ruling Thursday, it doesn't mean the law is set in stone, and it can be changed by an act of Congress.

According to the Kaiser Family Foundation, Iowa is one 18 states that is studying its options with regard to the exchanges. That effort, according to the website's state health facts, Republican Gov. Terry Branstad has been taking the lead in studying the options.

Iowa has so far received nearly $8.8 million in grants for working to establish the exchanges.

Branstad weighed in on the Supreme Court's decision, calling it disastrous and saying the law will lead to higher costs.

"As Gov. Romney has said many times, no matter what may happen in Court, the American people must remain vigilant in their fight to repeal the law," Branstad said. "Our goal is for Iowa to become the healthiest state in the country, and to do so, Iowans will need to take ownership of their own health to reduce health care costs and lead healthier lives."

Courtney believes despite Branstad's talk, the state will move ahead with complying with the state law and points out the nonpartisan Congressional Budget Office has said the law will lower health care costs over time. He said state Sen. Jack Hatch, D-Des Moines, who was appointed in 2009 to the White House Working Group of State Legislators for Health Reform, has taken the lead on moving ahead at the state level.

"I think Iowa is actually ahead of the game," said Courtney, adding he believes that will remain the case as long as Democrats keep control of the state Senate or control one of the legislative branches to help move legislation along. "I think we're headed in the right direction."

However, there are 15 states that already have set up exchanges. The remainder are at or below the level of activity in Iowa, with three states deciding against creating an exchange.

Heaton said the court's decision on the Medicaid expansion requires further review before he can comment on it and how the state will proceed.

The court ruled the Medicaid expansion is constitutional, but the federal government cannot penalize, by withholding all Medicaid funds, states who do not choose to participate in the expansion.

"We need a further explanation of that, because that could end up turning into tens of millions of additional state dollars needed to comply with the Medicaid expansion," Heaton said.

Hospitals move ahead

Spokespeople for area hospitals, in Fort Madison and West Burlington, said their plan is to comply with the law.

In a statement, the Fort Madison Community Hospital said the decision will not alter its focus on providing quality health care.

"While there will always be debate over the policy details, there remains a national consensus that everyone should have access to insurance coverage and delivery of care needs to be more efficient with higher standards of quality," the statement reads.

Craig Borchard, spokesman with Great River Medical Center, also said health care is always an evolving issue, and the hospital will continue to work with the Iowa Hospital Association on its lobbying effort to continue to improve and change the delivery of care.

"We've been working on delivery care needs, even before the discussion of the Affordable Care Act began, so we're still moving toward and working toward more efficient and higher quality care ... and integrating that care with our physicians, focusing on process improvement, care coordination, implementing more health information technology," Borchard said.

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