The Supreme Court virtually guaranteed sharper debate in the states, especially Republican-leaning red states, over whether to join the program the health care law establishes to expand Medicaid eligibility and coverage.
Those decisions will carry substantial stakes. Many of the conservative states most likely to opt out of the Medicaid expansion are also among the states with the largest number of uninsured.
National Journal has calculated that the 26 states that joined the lawsuit against the Medicaid expansion contain 27.6 million uninsured, a 55 percent majority of all the uninsured in America, according to Census Bureau figures. That includes Texas at 6.1 million uninsured, Florida at 3.9 million, and Georgia at 1.9 million.
That expansion was expected to provide coverage to about 17 million of the uninsured, roughly half of the total coverage expansion projected under the law. (The mandate on individuals to buy insurance, with substantial subsidies from the government and the establishment of exchanges where they can shop for competing coverage plans, is expected to provide the other half.)
The five-member Court majority struck down one aspect of that planned expansion: the penalty the law established for states that choose not to participate in the expanded coverage. The law said states that opted out could lose not only the funding relating to the expansion, but all of their federal Medicaid dollars — including their funding for the existing program.