June 29, 2012 -- The Supreme Court decision to uphold key provisions in the Affordable Care Act, or ACA, cleared up one question: Will the law stand (for now)? But for many people, that was about all they found clear.
There's still a lot of confusion about who will be covered, will the goal of insuring the uninsured be met, and what happens if I have preexisting conditions?
The court's decision did put a kink in President Obama's plan to extend health insurance to an estimated 32 million uninsured Americans.
More than half of the people meant to gain coverage under the health reform law were supposed to get free coverage under a major expansion of the Medicaid program.
That means, if you're struggling to make ends meet, you wouldn't pay a dime.
Now there's a hiccup in that plan.
After yesterday's decision, states cannot be forced to participate in the Medicaid expansion. That could leave millions of Americans without the coverage promised under the law.
"You've got a lot of conservative governors saying, 'You can't force us to expand Medicaid this way. We can't afford it,'" says Robert Laszewski, president of Health Policy and Strategy Associates in Alexandria, Va.
"Now the court has said, I think very appropriately and fairly, the feds can't take the original Medicaid funding away if you don't do the expansion," Laszewski says.
In effect, the ruling forces states to "put up or shut up," he tells WebMD.
"You don't want the money? You don't have to have the money. But then you go face your constituents and tell them why you didn't expand Medicaid like the other states," he says.
Who Pays for What?
Here's what the numbers look like. From 2014 to 2016, the federal government pays the entire cost of the Medicaid expansion. After 2016, the portion of the costs paid by the federal government begins to decline. By 2020, states would have to kick in 10%.
Ten percent may not sound like much, but some states are saying it could be financially crippling.
In Georgia, a state that sued to block the ACA, Gov. Nathan Deal says he's weighing his options.
''Even with federal help, the state would have to find another $4.5 billion over the next 10 years to pay for the Medicaid expansion.
In Indiana, Gov. Mitch Daniels said in a statement that the expansion would put 1 in 4 Hoosiers on the Medicaid rolls at a cost to the state of $2 billion over the next 10 years.
"I think states will turn it down," says Marc K. Siegel, MD, an infectious disease expert at New York University's Langone Medical Center in New York City, and also the physician coordinator of Doctor Radio.
"In New York, it's a billion dollars or more to administer the Medicaid expansion. So a key problem here is not in terms of Medicaid, which the feds are picking up the cost of for the most part, but the administration of the additional Medicaid patients," Siegel says.