The region's health care leaders are pleased and relieved about the Supreme Court's decision to uphold the Affordable Care Act, describing reactions ranging from "tears of excitement" to "pleasantly surprised."

At the same time, they acknowledge that many challenges lie ahead to making the law accomplish its intended purpose of making care accessible and affordable for individuals and bringing down the nation's overall health care costs.

"The most important part of this is to have the indecision decided, that there is a legal basis for the common-sense argument about committing the nation to specific goals it's never committed to before for the nation's health," said Dr. Michael Krinsky, neurologist and president of the Connecticut State Medical Society. "Now we have to get about finding a way to make this decision work in a way that's affordable, and there are real concerns about that."

He and others called the ruling the most important national health care decision since the creation of Medicare nearly 50 years ago, with wide-reaching ramifications for the health care industry, economics and politics.

Dr. David Thompson of East Lyme called the decision "great news," both for patients of his internal medicine practice who have struggled to obtain health insurance due to pre-existing conditions or cost, and for a group he's part of that's creating a new nonprofit insurance co-op, HealthyCT. The nonprofit received a federal start-up loan made available through the Affordable Care Act. If the law had been struck down, months of work organizing the new nonprofit would have been wasted.

"Now it will be moving forward," said Thompson, who is president of the Connecticut State Medical Society's Independent Practice Association.

For physicians and patients, one of the most potentially beneficial portions of the law is a provision that could raise Medicaid reimbursement fees to the same level as Medicare fees. The much lower rates paid by Medicaid, which covers people with low incomes, means a limited number of doctors have been willing to accept Medicaid patients, and those who do care for them at a loss. With the increase, Thompson said, access to care will be expanded as more doctors will be willing to take Medicaid patients.

For community health centers such as Generations, which serves patients in Norwich and several other eastern Connecticut communities, the law has brought in new federal dollars for expansion of programs and services, noted Arvin Shaw, chief executive officer. Provisions of the law that require everyone to have insurance, coupled with the creation of health insurance exchanges and making coverage available for people with preexisting conditions, he said, will motivate more people to obtain primary care services rather than wait until a condition requires costly emergency care. The act's emphasis on preventive services will also help curb costs, he believes.

"The real nuts and bolts of this will be how it impacts overutilization of the highest cost and most acute part of the health care system," he said. "Now, we're spending our health care dollars in the wrong places. We have had a system of sickness, and now, this puts the health back in the health care system."

At the Community Health Center, which has clinics in 13 towns around the state including New London and Groton, Dr. Nwando Olayiwola said her initial "tears of excitement" about the decision were tempered by the knowledge that the goal of the law will never be realized unless the pool of primary care doctors and nurse practitioners expands to meet the demand of newly insured patients.

One of the provisions of the act addresses the need for increasing the primary care workforce with loan forgiveness programs for those who work in poor communities. Connecticut, she said, also needs to continue moving forward with the steps it has taken to create a health insurance exchange.

"There are remaining challenges for Connecticut and the state legislature has to help us realize this act and implement it," she said.

Statewide, about one-quarter of the patients who go to community health centers are uninsured, said Deb Polun, director of government affairs and media relations at the Community Health Center Association of Connecticut. The act's expansion of Medicaid eligibility to those at 130 percent of poverty level will mean virtually all those patients can be covered by Medicaid, she said. They now pay on a sliding fee scale based on income, and oftentimes forgo care rather than pay out of pocket.

"We're thrilled with the decision," she said. "This means people will start getting health care treatment before it becomes an emergency."

She and others at the association, she said, were "holding our breath" over which way the court would decide.

'Noxious practices' eliminated

The Connecticut Hospital Association also praised the decision, as did both The William W. Backus Hospital in Norwich and Lawrence & Memorial Hospital in New London. "The high court ruling appears to be another positive step for health care reform," said Shawn Mawhiney, Backus spokesman. "However, a lot of work remains to be done. Universal insurance does not necessarily equate to universal access."

He noted the "fundamental issues" that need to be addressed, such as physician shortages, inappropriate use of emergency rooms and reimbursement based on volume rather than quality.

"We will all need to continue to work together - on the local, state and national level - to improve access to high quality, affordable health care for everyone," he said.

L&M President and Chief Executive Officer Bruce Cummings, saying he was "pleasantly surprised" by the decision, noted that the United States had been "the only advanced country that does not ensure that its citizens have universal access to a certain guaranteed minimum level of health care coverage."

The court's decision, he said, also means that certain "noxious practices" of insurance companies are eliminated. These include denying coverage to people with pre-existing conditions, imposing lifetime caps on benefits and dropping people from coverage when they become seriously ill.

"The decision significantly improves the prospects of the uninsured and intermittently uninsured to get consistently available basic coverage," he said.

He added, however, that another equally significant pathway of health care reform is under way - a transition toward a new system of assigning payments for health services. The shift, he said, is toward a system that assigns payments based on health outcomes rather than on procedures and tests.

Some, he said, would argue that is the "real" health reform because it means a "fundamental shift away from the way health services are paid for in this country." The transition had begun well before the court's decision, and will continue, regardless of how the Affordable Care Act fares moving forward, Cummings said.

j.benson@theday.com