In Florida, where about 3.8 million residents have no health insurance and millions more have feared losing coverage, the U.S. Supreme Court's ruling on the Affordable Care Act on Thursday could bring relief to many — but continued uncertainty to others.
"It creates a bona fide safety net that we didn't have before," said Jay Wolfson, a health policy expert at the University of South Florida.
"This doesn't guarantee 100 percent immediate coverage or access to care for all Americans. But it paves the way for increased access and more affordable access in a way that wasn't possible before."
Most Americans will be required to have health insurance coverage starting in 2014, and they will enjoy a wide range of new consumer protections.
Exchanges will be set up to give individuals access to group rates, and subsidies will be available on a sliding scale.
Because many won't be able to afford insurance at any cost, the law greatly expands Medicaid, the insurance plan for the poor.
But the ruling Thursday does give states some wiggle room on that expansion, and that could affect low-income Floridians.
The justices said Congress can offer money to the states for expansion, but it can't penalize those that refuse the funds, which require a small match from states. Florida Republicans led the challenge against the health law and have a history of turning down federal funds.
Other benefits of the new law, however, are clear with Thursday's ruling. Starting in 2014:
• Adults with pre-existing health conditions can no longer be excluded from health plans, or charged more for them.
• People can't be charged higher premiums because of age or gender — a real boon to women and people ages 50 to 64, who have paid more for years.
• Insurance companies can no longer cancel coverage when the policyholder gets sick.
As huge as the law is, it leaves many specifics up to further definition, such as how to accommodate so many newly insured patients, how the exchanges will work and what they'll cost.
"The devil will be in the details," said Wolfson, who is associate vice president for health law, policy and safety at USF Health. But he says enough is clear about the law to declare it a win for consumers.
Provisions of the law that already have taken effect and now will be retained include:
• Medicare beneficiaries can receive discounts on prescription drugs once they reach the "doughnut hole'' coverage gap.
• More than 50,000 people, including about 6,000 Floridians, with pre-existing health conditions in a temporary insurance plan created by the law will not lose their coverage.
• Millions of young adults under age 26 can remain on their parents' health plans.
• Women can continue to receive services such as mammograms and prenatal care with no out-of-pocket costs.
The individual mandate was the most controversial and unpopular part of the 2010 law, and the basis of the legal challenge by Florida and other states.
Many speculated the court would strike it down. But even opponents of the measure agreed that expensive provisions like guaranteeing coverage for those with pre-existing conditions would be impossible without it.
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Although many people have expressed opposition to the law, some say that's because they haven't yet benefited.
"A lot of Americans haven't felt the changes yet. I have because it saved my life,'' said Marlys Lenz Cox, a St. Petersburg woman who has battled breast cancer, hepatitis C — and $1,100 monthly insurance premiums she couldn't pay.
Under the pre-existing conditions program, she is covered for $376 and her cancer is in remission.
"I never really thought I would live a full life,'' Cox, 57, said of her struggles to get affordable care.
Now that the law has been upheld, "I feel like this has been made possible not so much by the legislators, but by the small people — the patients, the doctors, the advocates.''
Bob Shah, owner of Indian Shores Food Mart on Gulf Boulevard, is hoping the new insurance exchanges will drive down costs for his family of three. He has seen his premiums raised about 20 times since 1999.
"Every year they go up, even if I never go to the doctor," he said.
When he found out his premium would be increased again this past month, he opted to raise his deductible — the amount he pays out of pocket before coverage kicks in — to $10,000 to keep his costs down.
"I'm happy with today's ruling," he said. "I'm looking forward to the insurance exchanges."
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But health experts agree much work lies ahead.
Dr. Robert Brooks, associate vice president for health care leadership at USF, said a big challenge will be providing services for the estimated 30 million more Americans who will have insurance starting in 2014.
"We can't forget that to deliver these expanded or new services requires having doctors and clinics and hospitals able to see them and offer care when and where it's needed," said Brooks, a former secretary of health and Republican legislator who is seeking election to a House seat in Orlando.
Jan Humphreys, nurse practitioner at the Clearwater Free Clinic, said that could be especially challenging because Medicaid pays doctors less than Medicare or private insurance.
"Many providers don't handle Medicaid patients," she said.
Another big issue is educating consumers about the law.
"Some are individuals who have never had health insurance," said Jon Urbanek, a senior vice president for Florida Blue (formerly Blue Cross Blue Shield of Florida), the state's largest health insurer.
Dr. Claude Earl Fox, executive director of the Florida Public Health Institute, said misinformation is rampant.
"I've heard from one small business owner concerned that the law will put her out of business because she will be unable to afford to provide required health care, and from a gentleman on Medicare who has canceled his vacation plans for fear of spending money that he will need for health care,'' Fox said. Neither fear is grounded in truth.
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Among those who could be most affected by the health law are patients at local free clinics, which serve low-income people who haven't been eligible for Medicaid or couldn't afford insurance.
John Fielding, 31, has worked part-time at Publix for four years and on the $980 he makes in a month can't afford the company's insurance. He goes to the St. Petersburg Free Clinic to be treated for high blood pressure.
"I know the law requires people to get health insurance, but I really don't know how that's going to work out with me," Fielding said. He said he would welcome it if Florida expanded its Medicaid program to people like him.
Mindy Horowitz, 58, moved to St. Petersburg two months ago after being laid off from a job in North Carolina. After a while, she could no longer afford her insurance and sought help for her diabetes at the clinic.
She wasn't sure she could afford even less expensive insurance. But Medicaid, with its stigma of poverty, doesn't sound appealing either.
"I'm too proud and too embarrassed to go that far just yet," she said. "If this clinic didn't exist, I don't know what I'd do."
Beth Houghton, the St. Petersburg clinic's executive director, and Humphreys, of the Clearwater Free Clinic, say even with the new law there will always be patients who need them.
"We suspect there will always be a gap, and what our organization does is it sort of moves to where the gap is," said Houghton, who is offering more dental services.
"One would hope that the law would benefit them," Humphreys said of her clinic's patients. "But we'll have to see how this plays out.
"Our mission, our goals will not change — to provide care to people who have no access to care."
Times staff writers Anna M. Phillips and Charlotte Sutton contributed to this report. Richard Martin can be reached at firstname.lastname@example.org.