California has been in the forefront of states gearing up for full implementation of President Obama’s Affordable Health Care Act, and now that the U.S. Supreme Court has let stand its centerpiece, the individual mandate, and most of its other features it looks like the gamble may have paid off.

Diana Dooley, the California Health and Human Services secretary, said after the high court ruling Thursday that the state is “now in the full go mode,” and ready to utilize billions of dollars in federal aid already earmarked for its expansion of health care coverage. But tempering the enthusiasm and hovering over the horizon is the rejection by the majority of the law’s Medicaid expansion, Chief Justice John Roberts’ masterful majority opinion that lays the groundwork for the law’s demise and the pledge by GOP presidential candidate Mitt Romney to dismantle “Obamacare” if elected.    

Roberts was the unexpected fifth vote for passage, although he joined with other justices in undercutting Medicaid expansion by allowing states to opt out. He agreed with his fellow conservatives that the mandate to buy insurance was an unconstitutional use of the Commerce Clause or Necessary and Proper Clause, but thought it passed muster as a tax increase, the bane of many American voters. He supported the conservatives in opposition on every issue, but voted for the legislation on a technicality.

Romney has promised to exploit those weaknesses in the bill’s support to decimate it if elected with potentially dire consequences for California. Under the act, the state is expected to receive $45 billion to $55 billion from the federal government from 2014 to 2019 for expansion of Medi-Cal, California’s version of Medicaid. About 1.2 million Californians are expected to become newly covered.

The state almost certainly won’t take advantage of the ruling’s opt-out option, but Romney has said he wants to turn Medicaid entirely over to the states and cap its growth at inflation plus 1%. That would turn off the money spigot and make the program problematic for California. The state has already begun establishing the California Health Benefit Exchange and last week asked the federal government for $196 million to kick start enrollment. Romney also wants to let insurance companies sell their products across state lines, so if they find California’s rules onerous they can scoot over to Arizona and operate under fewer restrictions from there.

The key to California’s efforts is inclusivity; the more people enrolled in the health care system, the better it should operate. While President Romney might not be able to dismantle “Obamacare” on Day 1 of his new administration as promised, he can make it mighty tough on a state that has aggressively surged forward to begin construction of an untested health care system in hostile, unexplored political terrain.

–Ken Broder

To Learn More:

Supreme Court Ruling to Aid Poor, Uninsured—and California's Budget (by Chad Terhune, Los Angeles Times)

Supreme Court Decision on National Health Reform Law Keeps California Programs Intact (by Sandy Kleffman, Contra Costa Times)

Californians’ Big Win in Health Care Law Ruling (by Sandy Kleffman, Contra Costa Times)

High Court Rules in Favor of Federal Health Care Reform (by John Howard, Capitol Weekly)

Diana Dooley: California in “Full Go Mode” on Health Care Reform (by David Siders, Sacramento Bee)

What the Supreme Court's Health Care Ruling Means for Californians (by Katharine Mieszkowski, The Bay Citizen)

Romney’s Health Care Plan—or Lack Thereof (by Ezra Klein, Washington Post)

The Political Genius of John Roberts (by Ezra Klein, Washington Post)

Supreme Court's Healthcare Ruling: The Outlook for California (by Chad Terhune, Washington Post)