Nancy Cummings darted between her patients and her computer Thursday morning, waiting on word from the U.S. Supreme Court.

Just after 10 a.m. a friend texted her.

Upheld.

"For the average Mainer, it's a victory," said Cummings, an orthopedic surgeon at Franklin Memorial Hospital in Farmington and president of the Maine Medical Association.

In a much-anticipated, much-speculated 5-4 ruling, the U.S. Supreme Court upheld much of the Patient Protection and Affordable Care Act and its requirement that every American have insurance or pay a price.

Maine Attorney General William Schneider, one of 26 attorneys general who sued to stop it, found pockets of victory in the results: The court's majority ruled that Congress couldn't compel Americans to buy health insurance under the Commerce Clause but that the penalty for not having insurance amounted to a tax, which is allowed. It also took away the federal government's ability to threaten existing Medicaid, (MaineCare) funds if a state opted not to expand its program and accept new ACA money.

"I think the average Mainer can feel good about it, that the federal government is a government of limited powers, that the government can't step in and push Maine around as they were trying to do," Schneider said.

Maine Gov. Paul LePage called it "a sad day."

As news spread and people worked through the 193-page ruling, it was clear details remain to be sorted out, including what health insurance exchanges will look like and exactly what it will mean for Maine.

Rep. Sharon Treat, D-Hallowell, suggested the state budget would have to be revisited: It was balanced, in part, she said, on millions in anticipated savings from the ACA being overturned and more people moved off MaineCare. The other way to cut those rolls would be with a federal waiver, something the state has been told will be hard to come by.

"We passed — the Legislature, not including Democrats — passed a budget that was totally a house of cards," Treat said on a conference call with reporters.

She questioned whether Maine has time to set up a health insurance exchange, a means of comparing plans, finding out about subsidies and buying insurance.

"The law says the states have to tell the federal government by November (about plans), but even if they shifted that date, we haven't done what we need to do," Treat said. "This is a functioning thing that needs to work, both on the Web and behind the scenes. Just look at our current computer problems at DHHS. I don't think you're going to get that up and running in the space of a couple of months."

Barring a state exchange, there will be a national exchange come Jan. 1, 2014. "It's just not going to be tailored the way we might want to do it," Treat said.

In a written statement, LePage called the ruling a "massive overreach" that infringed upon the American Dream.

"This decision has verified what President Obama has refused to admit all along, which is to say this law is an enormous tax on the American people," he wrote. "The federal government can force you to do or buy anything, as long as they call it a ‘tax.’ This massive tax hike will only destroy the American economy as it forces us over the financial cliff."

Steven Michaud, president of the Maine Hospital Association, said cuts to Medicare reimbursement already under way to implement "Obamacare" are expected to cost Maine hospitals $900 million over the next decade.

"There are good things in it, but it was a very tough pill to swallow because we're already paid so poorly under Medicaid," he said. "The theory is hospitals will benefit from the expansion of coverage, 30 million nationally, but what our concern has always been, well, we know for sure the Medicare cuts are in because they're already phasing in now. We better hope like crazy more people are covered. That would in theory provide more revenue."

According to the U.S. Census Bureau, 129,000 people in Maine have no health insurance, which works out to one of the lowest rates in the country.

The individual mandate will bring more healthy people into the insurance market, which is a good thing for the system, said Andrew Coburn, professor of public health at the University of Southern Maine's Muskie School of Public Service.

"The biggest question mark is the Medicaid expansion provision (in) what I've seen so far," he said. Whether to go ahead and expand MaineCare and accept new money, "That's a question the Legislature will have to decide post-November."

Cummings in Farmington said more people covered by health insurance means more preventive care.

"Prevention is better than cure, anytime," she said.

She said she was surprised by Thursday's ruling.

"If you listened to the hearing, which I did, you were not overly optimistic," Cummings said. "It kind of renewed my faith in the system."

kskelton@sunjournal.com