The Affordable Care Act may now raise more questions than answers for each state since the Supreme Court’s ruling June 28.

Because the act gives power to each state to make decisions on Medicaid, insurance exchanges, health plan capacity and private insurance regulation among many others, the highly variable state responses over the next several months will likely define the overall implementation of the act in 2014 and for years to come.

State leaders identified ten categories of work and 109 milestones were broken down by the National Academy for State Health Policy, according to the State Health Policy Briefing in May 2010.

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States are trying to decide what is in their best financial interest, said Linda Renee Baker, an SIUC professor for the Paul Simon Public Policy Institute.

The reason the states will face so many decisions is because the federal government is a government of limited powers, and states were deemed sovereign entities when the country was formed, said William Schroeder, professor of law.

Among the list of decisions is the choice to expand Medicaid, a health care program jointly funded by state and federal governments that provides resources for low-income families, which Schroeder said is a very complicated issue.

Schroeder said the act initially stated not only should states expand coverage, but if they didn’t, then the program and funding would be taken away.

In a ruling of 7-2, the Supreme Court said the federal government couldn’t penalize the states for not taking advantage of a federal program, Schroeder said.

In less than five months, states must notify the Centers for Medicare and Medicaid Services by November 16 of their Medicaid decision, placing somewhat of a time constraint on the governors, legislators, insurance commissioners and attorneys general involved in the decision.

The decision will be whether the state will agree to develop a state-based insurance exchange, defer control entirely to the federal government and a federally-facilitated exchange or commit to sharing the responsibility of providing health care.

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Adrian Miller, a sophomore from Carbondale studying pre-law, said if states do not step in and support Medicaid, it will put a huge burden on the lower-middle class and the poor in this country.

“The problem can be that not everyone takes a step back and looks at the big picture,” Miller said. “Don’t just look at your own personal situation, but think about others.”

Schroeder said one effect to think about is the availability of providers and networks, especially with health care becoming more affordable.

With the encouragement to seek better care and more coverage, the ability to get a doctor’s appointment within a reasonable period of time may become even more difficult, he said.

“If you bring all these additional people into the system, there’s more patients for the doctor, which means a longer wait,” Schroeder said.

Schroeder said there’s also fear in the insurance industry about the unknown effects on smaller businesses, health care and health insurance providers.

Those selling health insurance may no longer be interested if they can’t make money doing it and may pull out of the business altogether, he said.

In the event companies pull out, availability of providers decreases and Medicaid is not expanded in certain states, improving access to care may become an issue.

Baker said the question will become whether states can sell enough insurance and put together enough networks to adequately serve its citizens.

She said improving access to care is hopefully what the Affordable Care Act intended to do, but the outcome is still very unclear.

“If I had a crystal ball, I would certainly look at how this will all play out,” Baker said. “Just because the Supreme Court made their ruling the other day, it’s far from over.”