KQED's Joshua Johnson talks with Marian Mulkey, director of the California HealthCare Foundation’s Health Reform and Public Program’s initiative.

JOHNSON: The Affordable Care Act stands to cover millions of Californians, 4-5 million Californians, bringing them more affordable care and better financial protection. And the ruling basically leaves that promise intact. What are your impressions of the justice’s rationales for how they ruled on the Affordable Care Act?

MULKEY: Well it was something of a surprise. My expertise is in health policy, not constitutional law or court watching, but it was something of a surprise that Justice Roberts joined with the liberals in finding this within the law under tax guidance, rather than under the commerce clause.

California has been a leader in kind of aggressively implementing these health reforms. I think it leaves us on the pathway that we thought we were headed down, which is helpful in that a great deal of work needs to be accomplished on a pretty tight timeframe t get the broad coverage expansion expected in 2014. It’s nice that California having gained some momentum toward expanding its medical program, towards establishing new rules in private health insurance market, that it can continue down that path without a lot of additional confusion or loss of momentum.

JOHNSON: Let’s dig into more of California’s reforms. Last year the state began offering coverage to low income adults ahead of the required expansion of MediCal in 2014. 400,000 low income, mostly childless adults , were getting covered in these interim programs ahead of that expansion. Will that continue on course.

MULKEY: It should. Those are generally speaking adults with significant health care needs and whose care is being much better organized and managed than it would have been without those local programs.

JOHNSON: Also, we have those preexisting condition programs, that was a big fight as part of the Affordable Care Act debate, how do you deal with people whose preexisting conditions prevent them from getting decent coverage. That includes people who couldn’t get covered because of their health history. About 11,000 people are in that preexisting condition insurance program, I’m guessing you feel that’s one of the ways California has lept out in front of rest of country.

MULKEY: I think most states have a version of that program, or they rely on the federal government, but clearly those are individuals whose health needs are great, and providing them comprehensive coverage at rates that otherwise available in the market, provides them with a very important level of access to health care.

JOHNSON: It seems like the piece of this that really had a lot to do with California’s efforts is this individual mandate – this requirement that everyone in America have health insurance coverage and if they didn’t have it on their own they had to use one of the government subsidized ways to get it to they would have to pay a fine.  That I assume would affect California’s health Benefits Exchange a clearinghouse to shop for coverage on its own. If there was no individual mandate that could have , I don’t want to say doomed the system, but it would have compromised it quite a bit wouldn’t it.

MULKEY: It would depend on how broad the court’s finding was. But the notion that insurers have to sell to all and the idea that there are options available fo everyone holds up much better if both sick and healthy participate in the marketplace. And the mandate is one tool, perhaps not a fool proof one, but one tool towards encouraging greater participation across all segments of the population.

JOHNSON: Do you see any more political fights in California about the future of this act?  The Republican presidential nominee Mitt Romney has promised to fight this tooth and nail and remove the act if he’s elected. What about California is that less of a political fight here?

MULKEY: I think there are remaining significant areas of uncertainty. The political environment is just one of them. But clearly there is continuing to be guidance coming from the federal government, potentially changes coming from Congress or the administration perhaps following the November election. And there are many important policy decisions connected to the implementation of the affordable care act that California still has to make. So it hasn’t left the political arena, but I think California remains on a fairly clear course forward toward the effective implementation of the law now that we know the law will stand.

Marian Mulkey is the director of the Health Reform and Public Programs Initiative of the California HealthCare Foundation.