California was the first state in the nation to start a new health insurance marketplace, following the passage of President Obama's health law. A staff of thirty-six is now part of what's called the Health Benefit Exchange. It's contracting to create a web portal that would eventually help consumers shop for insurance online. Exchange managers are discussing how, not whether, to use tens of thousands of people to help new enrollees navigate the system in the coming years. Peter Lee is heading up the effort.
"California has been moving ahead 100% assuming it will upheld, we believe it will be, and we aren't actually doing anything in the way of contingency planning because it makes no sense to plan for what seems like an outer bounds of possibility. And rather, we got a big job to do to to get ready to cover what will be millions of Californians in 18 months," said Lee.
Lee said his mission won't change even if the Supreme Court overturns the individual mandate to buy insurance, stating "the reason the exchange is going to have - we project - over 2 million people in it after a few years, is it's very little to do with the mandate. It has to do with we're a place where people can get subsidies for care, and can make informed choices."
But Patrick Johnston who speaks for California insurers said the federal law wouldn't work without a requirement to buy insurance.
"We need to have a group of people that is big enough and has enough people who for the most part are healthy to make sure that the insurance costs will be shared and not high," said Johnston.
Johnston said health insurance is like car insurance. It can't just include high risk clients. He said the federal law is like a three-legged stool that can't be pulled apart.
Johnston said, "states that decided to say 'Everybody gets insurance at the same price but you can buy it whenever you want,' found that prices just went way up and people dropped out."
California lawmakers have been moving forward with parts of the federal law since 2010. But would they - and the marketplace - keep pushing for a state health overhaul without the federal requirement that people buy in? Bill Monning said yes. He's the Chair of California's Assembly Health Committee.
"I'm going to remain fully committed to figuring out how do we preserve and protect what was the vision of President Obama, to replicate that in California by any means necessary," said Monning.
Monning and his counterpart in the state senate Ed Hernandez are hesitant to say they'd propose a state health insurance mandate, without knowing the court decision. But Hernandez said California should implement parts of the law that could be overturned, and he'd author bill that would address the issue of compelling people into the market. Still he said funding a new state marketplace without federal help, would be difficult.
"The state just doesn't have any money," said Monning. "And my biggest fear and concern is that we lose those federal subsidies, I just don't know how we can make it happen…work here in California."
But even Republicans like Assemblyman Dan Logue think the Democratic majority in California would propose and pass a state mandate in the absence of a federal one.
"They're trying to implement Obamacare right now," said Logue. "They're putting everything in place, and I think it's because they believe that if it is shifted to the states, that they'll already be ready to go."
Logue said President Obama's health law would lead to rationing and a mass exodus of business. If a state mandate were proposed, he'd take it to the voters.
"I think once they realize the dynamics and the cost and how it would put California at risk financially with the rest of the country, that it would go down in flames easily. But it will be a difficult fight," said Logue.
In a recent survey by the Public Policy Institute of California, more Californians supported the health law than opposed, but a majority were against the mandate.
While political will has already set changes to California health laws in motion, the scope of the new system will largely be shaped by the U.S Supreme Court decision.
