Several Republican governors, including Wisconsin’s Scott Walker, are already vowing to refuse federal dollars for the now-optional Medicaid expansion. Jonathan Cohn predicts most conservative states will eventually opt into the expansion after getting an earful from hospital executives who want reimbursement for serving low-income individuals, but that it may take a few years to achieve full participation. If that’s true, millions of people could be denied access to health care simply because they happen to live in a state where Tea Party ideology holds sway. The whole point of the expansion was to bring some much-needed uniformity to Medicaid eligibility and benefits rules, particularly in regards to poor adults without children. The Court’s decision undermines that goal and gives conservative elected officials yet another opportunity to score points with their political base while delivering an unabashedly gleeful “Fuck you!” to their poorer citizens.

I do think the expansion will be universally adopted–perhaps more quickly than we realize–but not before it becomes another election-year wedge issue. And not before plenty of elected officials utter some pretty horrible things about Medicaid and the people it serves.