THE impact of the Supreme Court ruling upholding the Patient Protection and Affordable Care Act, aka “Obamacare,” continues to reverberate across the U.S. In the mainland, at least, the announcement of the decision gives a certain finality to the issue. Whether one agrees with Obamacare or not, one can start work preparing for its many mandates. But here on Guam, like other U.S. territories, there are still a lot of gray areas that have to be resolved. As a result, healthcare stakeholders are still stumped as to what path to follow.

For instance, many thought the mandate that requires individuals to purchase insurance policies wouldn’t apply to Guam. But because the Supreme Court used the tax argument in upholding the law, the individual insurance mandate may now also apply to Guam since our island mirrors the federal taxation system.

Healthcare stakeholders on-island have already urged the Attorney General and the Insurance Commissioner to weigh in on the issue. Although the AG’s Office has asked for more time to study the issue, Insurance Commissioner Art Ilagan has already opined that the individual insurance requirement may not be feasible on Guam because of the relatively lower incomes on the island.

Under Obamacare, those who can’t purchase individual insurance policies would be subsidized. However, it is still unclear as to who will provide the subsidies – GovGuam or the federal government? Many fear this will be the EITC case all over again wherein the federal government sets up unfunded mandates that Guam and other territories must comply with, but without providing the funding for it. Or, at the very least, Guam may face another Compact Impact scenario where the subsidies provided by the federal government would be less than actual Compact costs.

If it turns out GovGuam will be the one in charge of the subsidies and the management of the mandated health exchanges, this would be an additional cost that GovGuam may not have the resources for. Under Obamacare, Guam does get an additional $268.3 million in Medicaid funding to be disbursed from Fiscal Years 2011 to 2019. However, the problem is whether GovGuam will have counterpart funding for this. The CNMI has already stated it may not avail of the expanded Medicaid program because it lacks the local funding to match the federal Medicaid dollars.

Another potential problem for Guam is the continuing lack of doctors and other medical professionals on-island. With medical treatments expected to skyrocket because of the new requirement for individuals to have insurance, the island may not have enough medical professionals to handle the increase in demand for medical treatment.

For the near term, the island’s healthcare insurance companies are facing the daunting prospect of paying some $15 million in rebates to GovGuam and individual clients. The deadline for this is Aug. 1, less than a month from now. Moreover, the new law has taken out the annual health insurance limits previously imposed by health insurance companies, especially for off-island coverage.

Some of these companies, already shaky even before Obamacare, are now being seen by analysts as finally keeling over and calling it quits.

One silver lining is that Guam’s health insurance market may be opened to outside, off-island providers, opening up competition and giving consumers more choices. The requirement to have every individual insured should make us attractive to off-island companies, but only to the deep-pocketed ones – the ones with enough capital to weather the initial heavy capital outlays required by Obamacare.

The downside is that because of the additional costs healthcare insurance companies will incur, insurance premiums may rise. Dr. Tom Shieh, president of the Guam Medical Association, has already released a preliminary statement, warning that health insurance companies may try to increase their premiums as people are required by the new law to buy their products. “You can rest assured that the insurance companies will find ways to limit or deny coverage and increase rates, someway, somehow. The worse thing (and it is already occurring) is insurance companies interfering with care by denying procedures that the doctors feel are needed for patients,” Shieh said pointedly.

But according to a Congressional Budget Office study, health insurance premiums may actually go down by up to 11 percent for firms receiving tax credits. Under Obamacare, small businesses that have fewer than 25 employees and provide health insurance can qualify for a tax credit of up to 35 percent (up to 25 percent for nonprofits) to offset the cost of insurance. This credit will increase in 2014 to 50 percent for small businesses newly offering insurance through private health insurance exchanges.

As long as insurance premiums remain reasonable, Obamacare could significantly improve coverage for individuals on Guam and prevent insurance companies from taking advantage of us since insurance companies will now be accountable to their customers for how they are spending premium dollars, and how much they are raising rates.

In addition, Obamacare provides free prevention benefits, coverage for young adults, coverage for people with pre-existing conditions, and lower-cost prescription drugs.

Of course, all of this may still depend on President Obama winning his re-election bid. With the Supreme Court’s upholding of the Patient Protection and Affordable Care Act, Obama rival Mitt Romney has made opposition to Obamacare the centerpiece of his campaign in the current U.S. presidential race. Republicans in the House of Representatives have also announced they will move forward with plans to repeal Obamacare despite the Supreme Court’s decision. If the House Republicans succeed or if Romney wins in November, we may very well be back to square one.