It was the best of times, it was the worst of times. Healthcare reform may not exactly be Dickens, but it’s a fitting description of how future generations might interpret the widely divergent responses to the SCOTUS decision on the Affordable Care Act and what came next.

One congressman likened the day’s event to the Sept. 11 terrorist attacks, though he later apologized for the remark. House minority leader Nancy Pelosi had cake.

State governors who will be responsible for doing much of the heavy lifting to implement portions of the Affordable Care Act in their states, like expanding Medicaid and setting up healthcare information exchanges, were equally divided in their comments on the decision. Delaware Gov. Jack Markell welcomed the decision. Pennsylvania Gov. Tom Corbett referenced the irony that the U.S. Supreme Court upheld the individual mandate to buy health insurance at the center of the act on the grounds that Congress has the right to tax citizens, a description of the provision that President Barack Obama denied.

Corbett said: “Not only is it a tax, but it may turn out to be one of the largest tax increases in the history of our nation. It is a tax on our citizens that they cannot afford. It is a tax that hits our small businesses the hardest and will kill job growth. … This is a burden to all of us who work every day to recover from the recession. ’ My administration will do all we can to ensure the negative impact of this law affects the lives of Pennsylvanians as little as possible,” Corbett said.

A hastily assembled panel discussion at University of Pennsylvania’s Institute of Health Economics, brought together in a crowded room a collection of legal, business and healthcare policy minds from Penn’s community, including Ralph Muller, the CEO of University of Pennsylvania Health System. It highlighted ways in which the act is and will impact patients.

For all the nervous excitement of some of the panelists and audience members saying they were pleased with the decision or the ACA in general, there was a palpable level of angst and uncertainty, best articulated by Scott Herrington, professor of healthcare management and insurance and risk management at Wharton.

Asked to describe potential concerns down the road, Herrington said he worries about a big cost surge on the horizon.

“We have all these people flowing into the individual market, and utilization could be higher than expected. ’ A lot of people even with subsidies are going to be facing higher premiums even if they have insurance. We have the expansion of Medicaid and the increase in demand for services from that. I’d like to see more discussion on what’s happening on the provider side to help ensure that come 2014, 2015, we will have some significant increase in the supply of medical care, or I think we will be facing longer waiting times and access seem to be much worse than they were prior to the law. What will happen if we have a big cost surge in the individual health insurance market — state budgets really start to be pounded. I think the types of policy discussions that could take place at the time could be substantial and profound that will make the issues surrounding the law seem much smaller.”

Although states have been offered economic incentives to set up healthcare information exchanges, many have taken a wait-and-see approach depending on which side the SCOTUS ruling favored. Now they may have to use one run by the federal government to catch up.

Muller said that experiments to reduce the cost of care would be ongoing as Penn’s health system and other institutions invest in healthcare IT systems and with the spread of accountable care organizations. “No matter what the scenario, keep your cost down and quality up and you’ll win.”

It was noted that states that had taken a wait-and-see approach on the SCOTUS decision before moving to set up a healthcare information exchange may have to use a federal contractor or third party.

Mary Naylor, a professor with the School of Nursing, despite being pleased with the decision, admitted: “I don’t think we have a panacea; we have a foundation in innovation that absolutely at some point will have to embrace the whole population to get us to high value.”

Although an upcoming presidential election could be a spoiler for the ACA, the consensus of the panel was states, hospitals and payers are too far along to turn back.

But the fear or angst generated from the budget uncertainties on states could have a significant influence on how the act is implemented state by state.

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