Joe Paduda at Managed Care Matters has posted the second of two parts in the special edition of Health Wonk Review responding to the Supreme Court’s decision on the Affordable Care Act: Part I is here, and Part II is here.

I’m delighted with the Court’s decision to uphold the law as a whole, but concerned about its making the Medicaid expansion optional. One Slate article and two posts on the Health Affairs Blog (one of which was included in Part I of the special-edition HWR) are especially helpful in thinking about the Medicaid aspect of the decision:

Darshak Sanghavi explains in Slate that the Medicaid expansion was the aspect of the ACA that was going to give the law the most impact, and writes: “… almost half of all people who qualify for free health insurance never sign up, especially in the Southern states where the highest number of uninsured people live. That’s not because inhabitants are lazy; it’s because those states create all kinds of barriers to Medicaid enrollment, since they have to assume some of the costs. The Supreme Court’s decision leaves the federal government without a big stick to beat ornery states like Texas, Florida, and Mississippi into expanding Medicaid, which means it has been left powerless to make sure that poor people get their coverage.”

Sara Rosenbaum, writing for the Health Affairs blog, describes how Chief Justice John Roberts fashioned a “Two State Solution” that “essentially saved the Medicaid expansion from extinction, while at the same time reaching a result that could satisfy any states’ rights aficionado.” The Chief Justice, she explains, has essentially created two different Medicaid eligibility categories with different enforcement options. While acknowledging that implementation will be slower and bumpier than under the original law, she is “convinced that millions of poor people ultimately will have the Chief Justice and Justices Kagan and Breyer to thank for figuring out a way not to let the money go.”

Also at the Health Affairs Blog, William Pewen takes us back to some legislative history of the Medicaid expansion, when lawmakers considered the issue of disparate Medicaid coverage between the states as well as the advantage Medicaid would have over private insurers in meeting the unique needs of this impoverished population. He addresses two concerns states have raised: an insufficient supply of providers who’ll see new Medicaid enrollees (addressed, he notes, temporarily by an increase in Medicaid reimbursement rates), and a potential jump in enrollment among populations that were previously eligible for Medicaid but didn’t enroll. To this enrollment concern, Prewen responds: “It is correct that the ACA does not offer an enhanced federal match to compensate for a state’s failure to implement its existing standards via effective enrollment efforts.  In such cases one may question why so many in a state were eligible but never enrolled – this suggests the absence of a good faith effort on the part of some states to even implement their programs as they themselves have designed them.”

Since my internet connection was a victim of storm damage for most of the weekend, I’m sure there are many more great pieces about the Supreme Court decision that I’ve missed — feel free to leave links to your favorites in the comments!