The state of Georgia, which delayed action on the federal health law in the hope that it would be ruled unconstitutional, will delay action again in the hope that Republicans win the White House and Congress and repeal the law.
Gov. Nathan Deal, describing the measure as the "largest tax increase in the history of the United States," said Thursday the state will hold off on two of the most important decisions it faces — whether to go forward with a giant expansion of Medicaid and with the creation of a state-run insurance exchange.
"Obviously, the elections in November will determine a lot of these decisions that will have to be made by the state at some point in time," Deal said at a news conference about four hours after the court ruled. "We are probably just going to be in a holding pattern until such time as we see what the events of November bring us."
Georgia Attorney General Sam Olens, who was with Republican presidential nominee Mitt Romney in Washington when the ruling was announced, said, "The main thing now is the Nov. 6 election, because what we really need to do is replace and repeal the act."
The Patient Protection and Affordable Care Act has vast implications for almost everyone in Georgia — from the one in five residents without insurance to countless businesses that will have to add costly new health benefits to the state's hospitals and doctors, who are wondering whether they will be able to adequately care for all the Georgians who will gain insurance in 2014.
"This legislation is far from perfect, but it does attempt to address the biggest problem that currently plagues our nation's health care delivery system: more than 50 million uninsured Americans," said Joseph Parker, president of the Georgia Hospital Association. "... We can change our focus to keeping people healthy rather than treating preventable illness in hospital emergency rooms. That will go a long way to containing costs."
Business impacts
The ruling also has important ramifications for businesses across Georgia:
- Large companies that offer benefits will have to continue to observe provisions already in place -- such as the requirement that parents may add adult children up to age 26 to their plans.
- Employers with 50 or more workers that do not currently offer insurance may face the most significant changes. The law requires them to offer insurance or pay a penalty if their employees obtain a federal tax credit subsidy through the new insurance exchange.
- Employees of some small businesses may benefit by being able to shop for coverage on the exchange. But many in business are worried about what the law will do to their balance sheets.
"This is an issue that our members have been very concerned about," said Karen Bremer, executive director of the Georgia Restaurant Association. She said some members have put off plans to expand because of uncertainty around the ruling.
Restaurants make a 4 to 10 percent profit on average, Bremer said. Paying $3,000 or $4,000 a year for insurance coverage for each worker could wipe out any profits they make, she said.
The impact of the law for many businesses won't be clear until Georgia has reached a decision on how it will handle key components of the law.
The uninsured
Nearly 2 million Georgians lack insurance, and the health care law was designed to extend coverage to most of them. Some Georgians would gain coverage starting in 2014 by shopping on the state insurance exchange, where many could qualify for income-based subsidies to help pay their premiums.
Under the law, insurers could no longer turn down people because they have pre-existing conditions.
Barry Guthrie, an Atlanta massage therapist, already gained coverage through a provision of the law that offered plans to uninsured people with pre-existing conditions. Guthrie, a cancer survivor, said he was worried the court might rule the law unconstitutional and leave him without insurance once again.
"I'm shocked and elated at the same time," Guthrie said Thursday. "It's going to be a good thing for a lot of people."
The expansion of Medicaid, the health plan for people with low incomes, was expected to add about 650,000 Georgians to the Medicaid program. The Supreme Court, however, ruled that states could opt out of that expansion.
Deal has opposed the Medicaid expansion, but he did not say Thursday whether the state would reject it.
Even though the feds would cover the vast majority of the cost of the Medicaid expansion, many governors including Deal are worried about the cost over the long haul. The program already covers roughly 1.7 million low-income Georgians and is facing a $300 million shortfall in the coming fiscal year.
Without the expansion, experts say, Georgia will still be faced with high numbers of uninsured residents -- adding pressure to the overall health care system, said Tim Sweeney, a health care analyst at the nonpartisan Georgia Budget and Policy Institute.
Taxpayers and people with insurance ultimately end up bearing the burden, experts say.
Doctors and hospitals charge patients with private coverage more to make up what they lose on caring for the uninsured, Sweeney said.
"Georgia can't afford not to do this," Sweeney said. "Georgia can't afford to have one of the highest uninsured rates in the country."
'Near capacity already'
At Grady Memorial Hospital in downtown Atlanta, a little more than a third of patients are uninsured and could gain coverage because of the law.
The hospital spent roughly $200 million caring for the poor and uninsured last year. More money from people insured through the insurance exchange or Medicaid would mean more dollars for Grady, but the problem wouldn't fully go away.
At least 600,000 people are projected to still be uninsured even with the law fully implemented, said Grady CEO John Haupert. "Where will the funding come from to provide care for those people?"
Hospitals could also see a jump in demand from people who have put off health care, Haupert said. And with Georgia facing a shortage of primary care doctors, people may end up at the hospital if they can't get appointments elsewhere, he added.
"It could create a strain on many of the hospitals in our market," he said. "Many hospitals are near capacity already."
States across the country are facing shortages of primary care doctors, who are typically paid less than many specialists. Georgia ranks No. 44 in the nation for primary care doctors, according to the 2011 State Physician Data Book.
Paying the doctors
Under the law, primary care doctors would see their Medicaid payments rise but only in 2013 and 2014.
Thursday's decision is irrelevant unless the government and insurers change how they pay physicians, said Sandra Reed, president of the Medical Association of Georgia, who was disappointed by the ruling.
The number of Georgia doctors practicing in the state's Medicaid program -- which pays less than the actual cost of care -- has dropped 15 percent in the past five years, Reed said.
"Physicians are going to continue to be forced to leave the Medicare and Medicaid programs in large numbers or face bankrupting their practices," Reed said. "That means it's going to be increasingly difficult for our neediest patients to find a physician."
In Georgia, Keith Abernathy hopes the decision to uphold the law will eventually enable him to get insurance coverage.
For most of his life, he had a full-time job and insurance but rarely used it because he was young and healthy. Now 63, Abernathy is scraping by on part-time work after being laid off from a full-time job in banking — an industry he worked in for more than two decades. He has applied in vain for full-time jobs with benefits.
Individual insurance would cost more than Abernathy pays for his house, so he depends on a free clinic in Gainesville for care. Now, he hopes the decision to uphold the health care law will allow him to get coverage going forward.
"I want everybody to have the opportunity to take care of their health from the time they're born to the time they die," he said.
Georgia has plenty of company in not taking action on the Affordable Care Act. As of March, the Associated Press reported, 13 states and the District of Columbia had created insurance exchanges
Other Republican governors have taken the same position as Nathan Deal in Georgia. Wisconsin Gov. Scott Walker said this week that the court's ruling didn't matter; he planned to do nothing on the law until after the November elections. South Carolina Gov. Nikki Haley and Florida Gov. Rick Scott have said the same, and South Dakota Gov. Dennis Daugaard joined them on Thursday.
Minnesota's Democratic governor, Mark Dayton, was such a strong backer of the act that he drew federal money to expand the state's Medicaid program last year — long before the court's ruling. California, which has already begun to create an insurance exchange, passed its own laws to make sure the measures stood even if the court's ruling disallowed them.
-- Aaron Gould Sheinin and Daniel Malloy contributed to this article.
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