After watching and waiting for nearly two years, we finally have more clarity surrounding the Affordable Care Act. The Supreme Court recently upheld the law's centerpiece — the individual mandate to purchase health insurance — as well as the rest of the law, with one exception.

In a surprise ruling, the court found coercive the ACA's Medicaid expansion, which required states to expand their programs for individuals earning up to 133 percent of the federal poverty level or risk losing all their Medicaid funding. The court ruled that the expansion could proceed but that the federal government could not threaten states with the loss of all of their Medicaid funding if they do not comply.

Many questions remain. The ruling leaves it up to the states to decide whether to participate in Medicaid expansion — and how they would exercise that option is unknown. As many as 16 million to 17 million people were predicted to gain access to coverage through the expansion. If states opt out, many of those individuals may go without coverage.

So where does this leave us?

First, it's full steam ahead with implementation of the ACA's reforms and new programs, such as the value-based purchasing program, accountable care organizations and demonstration projects. Other innovative efforts to improve quality and efficiency, such as the Hospital Engagement Network project ( will proceed. Trustees need to stay informed and ensure their hospitals are complying with the law's new regulations and taking advantage of its opportunities to improve care.

Second, we must work with our state hospital associations as our states roll out the Medicaid expansion. "Coverage for all, paid for by all" was one of the five pillars of the hospital field's Health for Life platform. Although not perfect, the ACA goes a long way toward reaching this goal, and the Medicaid expansion was to play a key role. Your state lawmakers need to hear how their decisions on the Medicaid expansion will impact the health of your hospital and community.

It's time to get to work.

Kimberly McNally, R.N., M.N. (, is COG chair and a trustee of Harborview Medical Center/UW Medicine in Seattle.