Despite all the heated rhetoric, the vast majority of states were already moving ahead with implementation of the sweeping federal healthcare reform bill signed into law by President Barack Obama in 2010, and experts say Thursday's Supreme Court ruling will only accelerate their efforts.
There are two major areas of work ahead for states, with one being the upgrade of their Medicaid technology and expanding the program's eligibility limits to new federal minimums, the other is working to set up state-based health insurance marketplaces known as "exchanges."
Exchanges are intended to create an easy method for individuals and small businesses to buy health insurance – they should be able to weigh different privately-offered plans against each other with apple-to-apple comparisons, something nearly impossible to do in the current market. States who decline to set up their own such exchanges will have federal officials doing it for them.
The Affordable Care Act, also known as Obamacare, is designed to provide states with grants and other subsidies for achieving both the Medicaid and exchange goals.
Deborah Bachrach, who served as New York's State Medicaid Director from 2007 to 2010 and has been consulting with states on ACA implementation issues since, says 46 states have taken either exchange dollars or the enhanced federal match dollars for Medicaid expansion or both Medicaid and exchange goals.
"The overwhelming majority of states, political rhetoric aside, are working to implement key aspects of the ACA," she says. "You can see this on the ground work going on right now – so that's your first signal that the train has left the station. States are building the systems they need to expand coverage."
Bachrach admits that some states—including many of the 28 states that filed lawsuits against the federal healthcare law—have been dragging their feet to some extent. But she argues with the ruling made, despite promises from GOP politicians that they will successfully repeal the law, states will nonetheless move forward.
"There may not be the enthusiasm at the top levels where the political rhetoric is strongest, but at the agency level, they will be moving," Bachrach says. "It will only really be a handful of states that will be doing nothing, because even the states that are most clear that they oppose the law and will 'do nothing' are already doing something."
One GOP governor, Michigan's Rick Snyder, already has asked lawmakers in his state to begin laying the groundwork for a state-based exchange.
"While I may not agree with everything in the law, now that the Supreme Court has essentially upheld the act, we must act quickly to avoid an undue burden on Michigan residents and job providers," Snyder said. "Working with our legislative leaders to establish the MiHealth Marketplace will allow Michiganders to make decisions regarding what will be covered, as opposed to Washington, D.C. making those decisions for us. It will also allow us to draw down federal dollars to assist with the costs of complying with the law."
Other Republican governors have taken a different approach.
"Wisconsin will not take any action to implement Obamacare," said Governor Scott Walker, who recently won a narrow recall election that garnered national attention. "I am hopeful that political changes in Washington D.C. later this year ultimately end the implementation of this law at the federal level."
Mila Kofman, a research professor at Georgetown University Health Policy Institute who served as Maine's Superintendent of Insurance from 2008 to 2011, says in addition to movement by states, insurers and providers have also already been moving ahead towards the law's implementation.
"Most of the businesses, the corporate world, they're not in la-la land. Once something is law, they are pretty much working towards compliance," she says.
Kofman, who supports the federal law, adds that instead of adding to government bureaucracy, the law has forced streamlining at the state level.