When the decision finally was announced in June, it gave senior leaders at least a modicum of solid ground upon which to begin making decisions about how to position their organizations strategically for the intermediate and long-term future.
"We know there's a need for radical change," Schnieders says. "It wasn't going to stop the train if they came back and ruled it unconstitutional, but it would have slowed down reform and it would have had to restart at some point in the future. Reform is going to occur one way or another and we would rather have planning and thoughtful preparation to deal with it. That said, even today, we're not really sure what the regulations are going to be, so there's still a lot of uncertainty about what will be required."
The two key decisions the Court handed down went in seemingly opposite philosophical directions. While the court affirmed the federal government's right to compel the purchase of health insurance, it said the feds were unable to force states to commensurately expand their Medicaid eligibility guidelines and set up "health insurance exchanges," that is, state-regulated, standardized health insurance plans from a variety of insurers available for purchase. While the federal government has promised to pick up 100% of the tab for the expansion for the first three years (2014–2017), it does ratchet down the feds' share to 90% by 2020 and future funding, given the national debt and deficit levels, is far from assured from future Congresses. For his part, Schnieders understands both sides of the argument regarding the Medicaid expansion. His state, Nebraska, is squarely on the fence from the legislative standpoint, but Republican Gov. Dave Heineman has vowed to oppose it, saying the state cannot afford to expand Medicaid.