Freed's concern is shared by Healthcare Financial Management Association President and CEO Joe Fifer, who says the ruling created "more uncertainty for CFOs than if it had been shot down altogether."
"Many of us are wondering what the implications of this will be on Medicaid—it's a big question mark," Fifer says. "We can't be sure how many uninsured people it will impact until each state decides what to do. The only thing we can presume is that there will be more activity toward establishing [insurance] exchanges in each state."
That poses another challenge for CFOs, as many states delayed establishing exchanges. To date 14 states and the District of Columbia have authorized creation of these exchanges, 33 states have taken initial steps or none at all, and three states have announced they won't participate in exchanges period. In the case of those states that refuse to participate or cannot find a way to do so, the law requires the federal government to run that state's exchange.
Some state officials argue that declining to participate in the Medicaid expansion will save money in the long term, even though it would likely carry repercussions from providers and advocates for the poor. Moreover, the Centers for Medicare & Medicaid Services has other ways besides legislative mandate to influence dissenting states to participate, such as the granting of special permissions.