All the health policy wonks are talking about the news of a federal judge ruling that the Affordable Care Act’s insurance mandate is unconstitutional. For those keeping score, two federal judges (appointed by Democrats) have ruled in favor of the mandate’s constitutionality while one judge (appointed by a Republican) has ruled against it. The latest ruling isn’t a surprise and the issue will ultimately be decided by Justice Kennedy (the other Supreme Court justices will simply cancel out each other’s votes). What is interesting about the judge’s decision is that he refused to strike down the entire law or stop its implementation.

This will create an interesting set of circumstance for the Court. States and insurers will continue to prepare for a post-2013 world of insurance exchanges and Medicaid expansions. If this ruling stands, those things wouldn’t go away, but it could create a lot of confusion and uncertainty for policymakers. Without a mandate, insurers will scream bloody murder about having to make insurance available to anyone who wants it. State exchanges might be made irrelevant after millions of dollars are spent on their planning and creation. How the Court does or doesn’t respond to these facts on the ground will give us wonks plenty to speculate about over the next couple years.

NPR continues its series on the ongoing struggle for people with disabilities and the elderly to receive care in the community rather than in nursing homes. Particular attention is given to working-age adults and children who are forced to live in nursing homes because states–many in the South–provide little or nothing in the way of community-based supports to enable them to stay at home. One of the stories quotes Carol Steckel, a former Alabama Medicaid director, who explains states’ continued reluctance to offer home and community-based services:

At a meeting of state Medicaid directors, in a hotel outside Washington, D.C., last month, Steckel noted many reasons states are reluctant to expand home-based care. How do you make sure people get good care at home? It’s easy, she says, to send an inspector into a nursing home. It’s harder to check on hundreds of individuals in their own homes.

And then there’s the money question. It’s a big problem for states facing all-time-high budget deficits.

“We’ve got people asking us to do 24/7 at-home care,” she says, “which means that we’ll be paying $500,000 for one individual. And then you have to debate as a society is that what we want to do versus taking that $500,000 and spending it on prenatal care for 10,000 women. I mean it’s a societal question, it’s a conundrum almost.”

With former bureaucrats like Steckel espousing such paternalistic and alarmist bullshit, it’s little wonder that people are still languishing in nursing homes. States are certainly facing significant budget deficits, but in most cases care can be delivered in the home for much less compared to a nursing home. And plenty of people already receive great care at home. Perhaps Steckel should pay a visit to Minnesota to see how it’s done.

I was going to write about how one intriguing element of the new Google bookstore is that books can be read on any web browser without additional software, but then Amazon just announced that its digital books will also be available on the web. Web-based reading isn’t anything revolutionary, but it’s a nice feature for those of us who might like to do a bit of lunchtime reading on office computers that don’t allow the installation of additional software. Both Amazon and Google will also allow independent booksellers to sell digital books through their websites and get a cut of each purchase. I’m hoping Uncle Hugo’s takes advantage of this arrangement so that I don’t have to feel guilty about not buying physical books from them anymore. Now, if only digital versions of the Harry Potter books would be released so that I can figure out what the hell was going on in the last movie.

The first full-length trailer for HBO’s forthcoming Game of Thrones series has arrived and it looks promising. Readers of the novels will recognize several major characters including Robert Baratheon, Daenerys Targaryen, Tyrion Lannister, and Boromir–er, I mean Eddard Stark. Sean Bean, who plays Stark, seems to be Hollywood’s go-to guy for any role involving a noble but tragic figure from fantasy literature. The trailer nicely captures the dark, foreboding tone of the first book and I’m eager to catch additional glimpses of the series when HBO airs a brief making-of documentary this Sunday. In the meantime, I’m almost done rereading the first book. Doorstop fantasy novels are much more manageable on a Kindle.

The Times reports on the abysmal conditions investigators found in Mexican institutions for people with disabilities. These facilities are little more than warehouses, as documented to disturbing effect in the accompanying video. The article describes how little government funding the institutions receive for basic supplies like toilet paper. Many of the residents are neglected and overmedicated with psychotropic medications. Some are even lobotomized. It’s a depressing reminder that international agreements and conventions on the rights of people with disabilities cannot improve conditions overnight in many parts of the developing world. The sad fact is that people with disabilities will continue to be victims of such medieval treatment until governments have been sufficiently shamed into doing better by their people.