Lisa Hill of Wildwood has a 17-year-old son with more health conditions than most people struggle with in a life time. He has coped with autism, epilepsy and leukemia. Hill says she has had no good place to turn for health insurance. But she felt hopeful on Thursday morning upon hearing that the Supreme Court had upheld the Affordable Care Act.

"The Supreme Court decided to allow my son to live," she said. "If his leukemia were to ever come back, it can be treated. That's what (the decision) means."

The ruling brought hope to others, too, including low wage workers employed at companies that provide no health benefits and people who automatically had been blackballed by insurers because of pre-existing health conditions.

An area resident who is somewhat optimistic about the ruling is Nancy Linder, 33, of Olivette. She has pre-existing health conditions that limit her ability to work and thwart her efforts to buy health insurance. She says she and her husband are trying to grow a small business, and he keeps his job at a large area corporation mainly for the health benefits. 

She eagerly awaited the court's  ruling on ACA, saying it will offer her better choices for health insurance while she focuses on growing the business. While she feels "a little more confident" now that the court has upheld the law, she says she's "not jumping up and down" because the outcome of fall elections might lead to a repeal of the health legislation.

"I've been denied (health insurance) multiple times," she says, adding that there is "no way I can get health insurance without the health care law standing." If the law isn't repealed, she's confident that by 2014, she'll have the option to purchase insurance coverage in spite of her health conditions.

Others were dismayed by the ruling. Marlott Rhoades, a former English as a Second Language instructor, isn't unsympathetic to the plight of some lacking health insurance. But he doesn't think insurance companies should have to automatically pick up the bill for those with pre-existing conditions.

He said that the 5-4 ruling will "cause unbelievable turmoil in this country for days and years and years to come. We're going to be fighting about this, trying to interpret exactly what the judges wanted," he said.

Another kind of cautionary note is voiced by people like Joe Pierle, CEO of the Missouri Primary Care Association, an organization that represents federally-qualified health centers across the state. He fears that ACA might not be as successful as some had hoped because the court gave states an opening to opt out of expanding Medicaid to insure more of the near-poor.

"This law could end up not being beneficial to patients we serve," he said. He and others explained that the contested legislation would have required Missouri to expand its Medicaid program to cover people with incomes up to 133 percent of the federal poverty line. That would have added about 250,000 uninsured people to the Medicaid program in Missouri.

But the Supreme Court ruling changes the Medicaid expansion mandate into an option. It left it up to states to decide whether to expand their Medicaid programs. Pierle feels that making the expansion optional amounts to telling states they don't have to provide insurance coverage to all of the needy. 

"Now that (mandatory) Medicaid expansion has been shot down, states like Missouri aren't going to offer" health insurance to all of those needing it, he predicts.

The irony might be that "the population least able to afford health care are still likely to be uninsured," he said.

That is a legitimate concern, according to Ryan Barker, health policy director at the Missouri Foundation for Health.  The big question he said is "What would Missouri do without Medicaid expansion?"

Some of the needy would have the option of getting health benefits though an insurance exchange program. They would be eligible, he said, because the program is open to people whose income is as low as 100 percent of the poverty level and as high as 400 percent of poverty.

Missouri has about 835,000 uninsured residents, Barker said. About 500,000 could get insurance under the act. That number includes  250,000 who would get health insurance if Missouri expands its Medicaid program. The other 250,000 could get health coverage through an insurance exchange system.

Barker praised the court for upholding the constitutionality of ACA.

"This is a huge step forward. It will allow doctors, nurses and other health care providers to get back to the reason they went into medicine," Barker said. "Doctors can spend more time with patients instead of dealing with insurance companies and paperwork."

Among others who also are pleased with the ruling is is Mark Burgess, a small-business owner with two children. He said the law will drive down health care costs, and he is especially pleased it allows his 20-year-old daughter to stay on his insurance.

Burgess, 47, said he pays about $12,000 a year to insure his family. He is "very happy" to have the ability to change insurance plans. "Without that, you're stuck," he said. "And if you have a preexisting condition, you're kind of screwed."

As a business owner, Burgess used to provide full coverage health insurance to his company's 16 employees. But rising costs led him to put more of the premium expenses on his employees. He said his insurance premium has gone up as much as 25 percent in a single year.

Fritzi Lainoff, 83, once bought prescription drugs from Canada because prices were cheaper than in the United States. ACA has come to the rescue with subsidies for seniors to help offset some of the cost of medications. Lainoff was surprised by the Supreme Court decision.

"I am very pleased with what’s come down today. Today is a very good day for the American people," she said.

 Dr. William Peck, director of the Center for Health Policy at Washington University, also is happy with the ruling.

"There have been no good alternatives to the organization and financing of health care," Peck said, adding that the individual mandate in the law is valuable in making care accessible to the needy and those with pre-existing conditions. But he still has concerns.

"ACA addresses (some) issues. I am pleased that much has been approved. But a major problem is that it doesn't offer a game change to health cost. Maybe it will help to bring the cost curve down. You have to give this law a chance to work."

Some doctors, however, aren't so optimistic.

"Life goes on and (health reform) won't stop physicians from practicing medicine and taking care of patients," said Dr. Jeffrey Thomasson, a neuroradiologist in West County. "My big concern is that we are creating a lot more government agencies that are getting involved in oversight. That costs money and those dollars could be used for health care."

He's convinced that the law won't save money because "whenever we have a program, not just in government but in the private sector, it ends up costing more than it was supposed to cost. So I'm convinced this is actually not going to be a savings, but a burden on taxpayers."

Still, he said there were a few good ideas in the law, including the rule to prevent people from being denied health insurance due to pre-existing conditions.

Thomasson said the system wasn't perfect before ACA, and that questions should be raised about how to care for the underserved. But he said solutions should be found that don't adversely affect care for those being served well by the system.

"The attempt was to do a global fix of everything perceived as wrong. It makes more sense to fix one thing at a time."

Months before Congress passed the health reform law, Tim McBride, associate dean for public health at Washington University's Brown School of Social Work, described the period as a perfect storm for health care reform. But once the storm reached the Supreme Court, the justices didn't line up the way he had expected. He had assumed Justice Anthony Kennedy might side with the court's liberal wing. McBride was taken aback upon learning that Kennedy had been among the four minority justices who wanted the court to void ACA.

"But the ruling was a very smart decision," McBride said. "They upheld the mandate and, on the whole, this is a major victory for health care."

The impact of ACA already has been far-reaching in Missouri. One of its most popular provisions allows young adults to stay on their parents' health plans until they turn 26. By June of last year, according to the federal government, more than 39,000 young adults in Missouri got insurance coverage as a result of the law.

The government cites these other benefits to Missouri residents:

• A discount drug provision for seniors in Missouri saved an average of $595 for each Medicare enrollee, and a total of $46.7 million.

• More than 729,800 people in Missouri got free preventive services -- such as mammograms and colonscopies -- and free annual wellness visits with their doctors.

• The law forced insurers to stop imposing lifetime dollar limits on health benefits.

• More than 1,000 uninsured residents in Missouri got insurance in spite of having pre-existing health conditions that otherwise would have precluded them from getting coverage.

Dave Dillon, vice president for media relations at the Missouri Hospital Association, couldn't find any disappointments in the ruling.

"ACA obviously is a significant expansion of health insurance," he said, noting that the ruling means hospitals and other providers will have to accommodate more patients partly because more people will have access to health insurance

"We know now what the rules are going to be," Dillon said. "Although everything has changed, our mission hasn't changed."

Some church leaders were unhappy with the ruling. The Rev. Dr. Matthew C. Harrison, president of the The Lutheran Church - Missouri Synod took issue with the law's "birth control mandate." He said in a statement that the mandate "runs counter to the biblical truth of the sanctity of human life and creates a conflict of conscience for religious employers and insurers, who face steep penalties for non-compliance based upon their religious convictions."

He said the church would stand with those who have filed suit in "many religious freedom cases pending against the birth control mandate," and would "continue working to ensure our right to refrain from paying for products and services that conflict with our doctrine about the sanctity of all human life."

Planned Parenthood also called attention to services for women in its reaction to the law. It said the decision upholding the Affordable Care Act was “the greatest advance in women’s health in a generation," adding that the law will have a “profound and concrete impact on millions of people’s lives.”

"This is a victory for the American people, and we thank President Obama and the members of Congress who passed the Affordable Care Act for their leadership on this issue.” said Cecile Richards, president of Planned Parenthood Federation of America.

Abby Abrams, Molly Duffy, Nicholas Fandos, and Lauren Leone contributed to this report.