While some states dragged their heels, Washington lawmakers moved ahead, passing laws, applying for grants and hiring staff to implement requirements of the federal health-care law.

Some states, unenthusiastic about the federal health-care law and supportive of efforts to overturn it, dragged their heels on implementing its requirements.

Not Washington.

Betting on the come, the Democrat-controlled Legislature and policymakers here moved ahead, passing laws, applying for grants and hiring staff — some of whom started work just weeks ago — all in preparation for a federal law that was still in legal limbo.

They could have looked really dumb.

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As it turned out, the court upheld the Affordable Care Act (ACA) on Thursday with a bit of relabeling of the individual mandate, the requirement that everyone have insurance or pay a penalty. It’s not a mandate, the court said, it’s a tax. And that’s constitutional.

“Yippee!” shouted State Rep. Eileen Cody, chairwoman of the House health-care committee, early Thursday morning. Cody said she had worried about how the decision might affect many projects aimed at changing how health-care works in this state, particularly for the 1 million people without insurance.

“I feel like the momentum has been building, and I was worried that if something happened to the ACA, we’d lose that,” she said. “Now I think we can continue.”

The ruling clears the way for the state, beginning in 2014, to enroll low-income adults without dependent children or severe disabilities in Medicaid.

The state also will continue work on the Health Benefit Exchange, where small businesses and people with low to moderate incomes — with federal subsidies — can shop for private health insurance, easily comparing benefits.

Challenges ahead

As a lawmaker and a working nurse, Cody knows well there are many serious challenges ahead. They include the vows of Republican presidential nominee Mitt Romney and U.S. House Speaker John Boehner, to overturn “Obamacare.”

State Sen. David Frockt, D-Seattle, who serves on a state legislative committee on health-reform implementation, predicted that threats to repeal the law will be a “core issue” in both the national presidential campaign and the race for governor in Washington.

He said he is puzzled by conservative antipathy toward the exchange, a private-market approach once endorsed by Republicans and conservatives — as well as Romney, who as Massachusetts governor supported a similar program as part of a statewide health-care overhaul effort.

The plan, as outlined in the federal law, calls for people with incomes between 139 and 400 percent of poverty level to be eligible for federal subsidies, given as refundable tax credits.

Critics of the approach, including many doctors, complain that the federal subsidies amount to a windfall for private insurers, said Frockt, who takes a pragmatic approach.

“I think it’s a market mechanism that we can make work,” he said.

Another worry is the state’s budget crunch.

The state estimates that under the federal law, state Medicaid enrollment may increase by up to 42 percent in the several years after 2014. Some of those new enrollees will be childless adults with incomes less than 138 percent of federal poverty level — the expansion authorized under the law and funded primarily by federal dollars.

After 2019, the federal payments drop to 90 percent, and the state must pick up the rest. In a dissent to Thursday’s ruling, four justices noted that states will be “forced to shoulder substantial costs.” If funding terms change, they said, states could be left with “an increasingly large percentage of the bill.”

The state also expects to bring in an additional 170,000 or so who qualify, mostly children, under the old rules. That means the state would have to cover half their costs, which officials say they can’t yet estimate.

The Washington Policy Center, which advocates market-based solutions, said Thursday state lawmakers should not agree to the Medicaid expansion without fully understanding “the long-term impacts on an already tenuous state budget outlook.”

Might Washington opt out of the Medicaid expansion?

Doug Porter, director of the state’s Health Care Authority, which administers Medicaid, says no.

“Washington state has no plans to withdraw from Medicaid or reduce current eligibility thresholds,” he said.

Cody says she’s also worried about health-care costs in general.

“We really have to work together with providers to figure out a better way to streamline health care,” she said.

She and others say access is another big problem.

Many private clinics and doctors now limit or don’t take Medicaid patients. Washington state has 5,971 primary-care doctors active in patient care — one doctor per 1,143 state residents — according to the Association of American Medical Colleges.

But a state survey found only 5,498 primary-care doctors who see patients in offices or clinics. And there was wide geographic difference in access, with about 40 percent practicing in King County.

Nearly half said they won’t take new patients or Medicaid patients.

Even if the additional patients are slowly enrolled in insurance over two or three years, said Aaron Katz, a health-services expert at the University of Washington, there’s wide concern that the sheer numbers will strain the capacity of primary-care providers and community clinics.

“There are a lot of holes in the health-care system,” said Dr. Alan Chun, a family doctor who practices at the International District Clinic in Seattle.

He often sees patients, including many elderly, who can’t be seen elsewhere, either because they are un- or underinsured or because other providers won’t accept Medicaid, he said.

Moving ahead

“We in Washington have tried to do health-care reform since 1993,” Cody said, referring to a statewide health-reform law that was essentially gutted when Republicans swept into state office in the 1994 election.

Now, she said, it appears Washington may finally have the tools — and money — to make progress on expanded access.

But not everyone was as enthusiastic about Thursday’s decision.

Washington Policy Center’s health-care analyst, Dr. Roger Stark, a retired heart surgeon, said the law amounts to the largest tax increase in history, which will deepen the national debt and ultimately result in higher costs, fewer choices and worse care for families.

Instead of new entitlements, Stark said, lawmakers should abolish the third-party payer system, where insurers and governments foot medical bills, and let the “free market flourish” by letting patients choose and buy health care themselves.

But even Stark said there has been a silver lining to the long controversy over the federal law: “It’s focused the entire country on health care and the necessity for health-care reform.”

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com.

On Twitter @costrom.