Xavier Alvarez got twin pieces of good news Thursday. First, thanks to the Court’s decision in the Health Care Cases, Medicaid in California may soon be funded to supply mental-health services to crazed compulsive liars like him. Second, and of more immediate interest to him, he won’t be doing a year in the federal slam for falsely claiming to have won the Congressional Medal of Honor.

The verdict of the Supreme Court upholding nearly all of the Affordable Care Act is a victory to be savored in the full knowledge that it may be only temporary and includes potentially damaging changes in constitutional interpretation.

It is a victory, first of all, for the millions of people excluded from health insurance who stand to gain protection despite their medical history or low incomes.

It is a victory for the rule of law in the face of a group of partisan conservative justices who want to immobilize federal power in social policy.

It is a victory for the millions of people who have struggled for decades to achieve equal access to health care.

As the lawsuits challenging the Affordable Care Act worked their way up to the Supreme Court, I always found the challenge to the expansion of Medicaid to be the strangest part. Quick context: the program provides insurance for poor people, splitting the cost between the federal government and the states. But the current rules say that each state gets to set its own eligibility standards, which meant that if you live in a state run by Democrats and you're poor, you can get Medicaid, but if you live in a state run by Republicans, you have to be desperately poor to get Medicaid. For instance, in Mississippi, a family of four has to have a yearly gross income below a princely $9,828 to qualify. Because if a family is living high on the hog with their $10,000 a year, they aren't really poor, right?

Fortunately, the Affordable Care Act fixed this, by changing Medicaid so that everyone with up to 133 percent of the federal poverty level ($30,657 for a family of four) would qualify. And to make things easier on the states, the bill provided that the federal government would pick up almost all of the tab. The federal government pays 100 percent of the cost of paying for the new enrollees through 2016, 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and 90 percent from then on. In other words, the federal government is saying to states, "Here's a bunch of free money to insure a whole lot of your citizens, which will make them healthier and more productive." And almost every state run by Republicans replied, "How dare you do such a thing to us! It's unconstitutional! We're suing!"

It’s only a bit after 8 a.m. and Russell Mokhiber is shouting at a belly dancer in front of the Supreme Court of the United States.

Granted, it’s out of concern—it’s the kind of Washington, D.C., summer morning when it feels like the air is one giant dog’s tongue licking your body, and the lady in question, Angela Petry—a middle-aged sandy blonde with the abdominal muscles of an 18-year-old pageant queen—is his wife. She’s been dancing up a storm, a whirl of skin, red and blue silk scarves, and beads dripping from her bosom.

On the fourth day of the Battle of Gettysburg, General Richard S. (“Bald Dick”) Ewell, riding behind the lines, was hit in the leg by a Union sniper’s bullet. Unfazed, the one-legged general remarked, “It don't hurt a bit to be shot in a wooden leg.”

It may be that the federal government was shot in a wooden leg today. Overall, that’s true—the ACA survived, by one vote, a case that could have voided it in its entirety and wreaked havoc on federal power generally. But in particular, in the Court’s major new cutback on federal power—the limits on the use of Congress’s spending power to convince the states to sign on to an expanded Medicaid program—the federal government was wounded by being forbidden to do something it really never wanted to do. 

For supporters of the Affordable Care Act, it was hard to hear—over the cheering—anything besides the fact that the Supreme Court today kept the law almost entirely intact. But the Court did make a slight change to a crucial part of the ACA: Medicaid expansion. Under the law, by 2014, states are supposed to extend their Medicaid programs to cover people under 65 with incomes up to 133 percent of the federal poverty line. An analysis from the Center on Budget and Policy Priorities shows that means 17 million more people would have access to health care over the next 10 years.  Before today, it looked like states didn't have much choice in the matter.

• Ten Reasons American Health Care is So Bad, Ezra Klein (November 2007)
  Of all the countries surveyed in a recent poll, Americans were the least likely to report relative satisfaction with their health care. Here are ten major ways our system is failing us.
• The Cost of Delayed Reform, Harold Pollack (July 2010)
  The temporary federal high-risk pools won't reach most of the medically uninsured.