In the weeks and months to come, the long-term care industry will digest and analyze the impact of today’s momentous Supreme Court decision, which upheld the constitutionality of the Affordable Care Act. Today, several LTC leaders shared with Long-Term Living’s editors their initial reactions to the decision, which ranged from concern and uncertainty over escalating costs and government oversight to elation over the survival of various healthcare reform initiatives.

“More people need healthcare and access to the exchanges that enable them to get low-cost healthcare,” says Diane Carter, RN, MSN, RAC-CT, C-NE,  President/CEO of American Association of Nurse Assessment Coordination (AANAC).

But hospitals, nursing homes and other care settings will need to work much more closely together because payments will be bundled, she adds. “We have to continue to make alliances with other care providers along the continuum as part of ACOs,” she says. “There’s no going back. We have to continue to move our efforts forward and implement the steps we need to take over the next four or five years.”

Larry Minnix, president and CEO of LeadingAge, told Long-Term Living, “We’ve supported the Affordable Care Act for all the reasons that have been acknowledged but [also for] some that don’t get highlighted. First, it paves the way for innovation around integrated care, especially for lower-income dually-eligible populations. Second, this helps seniors with their medication bills and third, it has the CLASS act in it which is truly a way to obviate the costs of long-term care to the taxpayer.”

Minnix reports that feedback from LeadingAge membership has ranged from “hooray” to “this is a sad day for America.”

“Everybody cares for the elderly and their employees; that’s not the issue,” Minnix says. “The issue is more the perception that the federal government has too little or too much control over people’s lives. We’re respectful of the fact that we have some people who didn’t like the decision. But they share the same commitment as everyone else to really good care and services to the elderly.”

Minnix tells his members they have an innovation responsibility. “The current way we’re taking care of seniors in this country is unsustainable and unaffordable,” Minnix says. “The only way out is innovation so we’re encouraging people to get together with their Medicaid program and help figure out ways to keep people at home less expensively, and work on a focused way on avoidable hospital and nursing home admissions. At the same time we’re saying to every state legislature and member of Congress, you cannot continue to cut nursing home Medicaid rates because you can’t take care of increasingly sick people with the kind of rates some of our states are getting.”

The ACA will impact long-term care by including a previously uninsured population, a situation that “on the surface seems tremendous,” says Eli Pick, president, Post Acute Innovations, in an email interview. “A huge number of people [will be] eligible for SNF coverage that heretofore [have] only been able to get acute services for emergency care. The type of coverage is the crucial question.”

“The anticipated outcome of converting Medicaid to an insurance program is the diluting of the insured population that are currently receiving SNF services and significant reductions in the rates that are paid for this expanded population,” Pick continues. “This will take years to be fully implemented with insurance exchanges targeted for implementation by 2014, and that sets up the infrastructure to begin the process of establishing coverage for all the uninsured and also transitioning the existing Medicaid covered into the insurance pools. The decision is monumental in that it validates the process, but how things will look when all is said and done is far from clear.”

The retention of the individual mandate should promote better patient engagement and bolster disease management, says John Alfano, president and CEO of LeadingAge Ohio, a nonprofit serving 400 providers and facilities across the state. “By having some sort of health insurance, most people do better with preventive care. They’ll go to a doctor right away instead of waiting until their condition escalates and they have to go to the ER.”

But Alfano shares some concerns over how the ACA will affect his organization’s member populations. “Hospitals, physician groups and managed care companies have much more authority over placement. If you’re not one of their panel providers, you can be shut out,” he says.

With confirmation of the ACA, changes in healthcare delivery and payment are now “full-speed ahead,” says Kathleen Griffin, PhD, national director of post-acute and senior services at consulting firm Health Dimensions Group, and an expert on integrated health systems. Griffin expects to see hospitals and healthcare systemssearch much more aggressively for preferred partners in post-acute care as they begin to develop their integrated post-acute delivery systems in order to take on more payment risk and move toward population health management.

“If anything, long-term care, post-acute providers really need to be expediting their initiatives to be internally capable of managing medically complex patients and to have a primary care strategy within their facilities so that they can be the care managers for at-risk residents,” Griffin says. “And senior living campuses need to be looking at their entire care management strategies to determine how they might be able to package them along with metrics in order to be able to subcontract with the entity holding the money as the care manger for this group of what we call attributable lives in an accountable care organization.

“The more forward-thinking post-acute providers and hospitals will continue down the same path they’ve been on,” Griffin says. “Those who haven’t been thinking about it are going to start falling, whereas before they didn’t. The train has left the station and [if you haven’t already] you better hop on a station down the line because you’re already behind.”

Two hours following the Supreme Court’s ruling, President Obama addressed the nation in the wake of the decision.

“The highest Court in the land has now spoken,” President Obama said. “We will continue to implement this law. And we'll work together to improve on it where we can.  But what we won’t do—what  the country can’t afford to do—is refight the political battles of two years ago, or go back to the way things were.”

The ACA became law in 2010 amid much congressional division. The law is the biggest revamping of U.S. healthcare since the 1965 creation of Medicare and Medicaid.