The most ambitious health care reform since the 1965 creation of Medicare has withstood the test of constitutionality at the U.S. Supreme Court. It is a huge victory for millions of Americans and for fairness, but it is by no means secure.

Thursday's 5-4 decision will go down in history as a landmark. It marks a crucial point for the United States in moving toward the goal that all citizens should have access to decent, affordable health care.

If the court had struck down the law, which it nearly did, that cause would have been set back for decades.

Chief Justice John Roberts saved the day, ensuring that Congress and the president – who are accountable to the people – will not be strangled in their efforts to take on the national challenges of our time.

Justice Anthony Kennedy, the Sacramento native who spoke for the four dissenters, said: "In our view, the act before us is invalid in its entirety." With that one line and the national spotlight on him, Kennedy erased his reputation for moderation. Sadly, Kennedy chose to be on the wrong side of history.

Judicial restraint

Roberts made clear, with an elegant argument, that the court should allow the people through their elected representatives to make policy judgments:

"Those decisions are entrusted to our Nation's elected leaders, who can be thrown out of office if the people disagree with them."

The November election will decide the fate of the Affordable Care Act, as it should. Supporters need to make their voices heard at the ballot box.

Impact on California

This state has 8.2 million uninsured residents. They deserve better. The court's decision will ensure that many of them will get health insurance coverage.

By 2014, between the individual mandate and the new state health exchange, 2 million to 4 million uninsured Californians will be able to afford insurance. With the coming expansion of Medicaid, called Medi-Cal in California, about 2 million more people will get insurance. Young people between the ages of 19 and 26 will be able to stay on their parents' policies.

And those of us fortunate enough to have health insurance will get better consumer protections to prevent insurance industry abuses – and a reduction in the burden that those without insurance put on those with insurance. That cost-shift adds, on average, more than $1,000 a year to family insurance premiums.

Individual mandate

The law requires individuals to acquire coverage or make a "shared responsibility payment" through the Internal Revenue Service.

If the Massachusetts model – led by Mitt Romney, then governor, now presumptive Republican presidential nominee – is any guide, the vast majority of people will choose to buy insurance. Only 2 percent of Massachusetts residents are uninsured, the lowest share in the nation. The number of people getting free care at hospital emergency rooms there has been significantly reduced.

Those who are now blasting the "shared responsibility payment" as a tax – the alternative for those who don't buy insurance – ought to consider the unconscionable burden that cost-shifting places on Americans. We all pay when indigent people show up at emergency rooms.

Expanded Medicaid

State and local government will be relieved of some costs for uncompensated care of the uninsured. To encourage states to opt-in to an expanded Medicaid, the Affordable Care Act calls for the federal government to pay 100 percent of the costs for newly eligible Medicaid enrollees for the first three years. After the temporary three-year full ride, the federal government will pick up 90 percent of the cost. That's well beyond the current 50-50 share.

That continues under the court's ruling. What doesn't hold is the penalty for states that opt out of the expansion – taking away their existing Medicaid funding. So some states may opt out, but not California.

If any states choose to opt out, voters in those states should rise up and elect legislators who will opt in.

The response

President Barack Obama's response was measured – not triumphant: "The highest court in the land has now spoken. 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."

He also began to explain, as Democrats should have been doing all along but have failed to do, what the law actually does in terms that people can understand.

Romney created Romneycare and its individual mandate in Massachusetts. Nonetheless, he drew clear lines for an election battle: "Obamacare was bad policy yesterday; it's bad policy today."

The fight now moves to the ballot box where it belongs.

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