A divided federal appeals court has temporarily barred the U.S. government from requiring an Illinois company to obtain insurance coverage for contraceptives, as mandated under the 2010 healthcare overhaul, after the owners objected on religious grounds.

More than 40 lawsuits are challenging a requirement in the Patient Protection and Affordable Care Act that requires most for-profit companies to offer workers insurance coverage for contraceptive drugs and devices and other birth control methods.

Friday's 2-1 order by a panel of the 7th U.S. Circuit Court of Appeals in Chicago in favor of Cyril and Jane Korte was the second by a federal appeals court to temporarily halt enforcement against people who said it violated their faith, said Edward White, a lawyer for the Roman Catholic couple.

The 7th Circuit suggested that the couple's legal challenge might eventually prevail.

Its order came two days after U.S. Supreme Court Justice Sonia Sotomayor declined to block the provision's enforcement against companies controlled by the family of Oklahoma City billionaire David Green.

The U.S. Department of Justice, which had defended the contraceptives provision, did not immediately respond on Saturday to a request for comment.

The Kortes, who own the construction firm Korte & Luitjohan Contractors, had sought to drop a health insurance plan for 20 non-unionized workers that included coverage for contraception, and substitute a different plan consistent with their faith.

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But the Obama administration's healthcare law did not allow the change, and the Kortes said that violated the First Amendment to the U.S. Constitution and the federal Religious Freedom Restoration Act, or RFRA.

In issuing an injunction, the 7th Circuit majority said the Kortes had established a reasonable likelihood of success on the merits of their RFRA claim, and that the government had not yet justified the apparent "substantial burden" on their religious exercise.

The court also said the couple had established irreparable harm, because absent an injunction they would have to choose between maintaining insurance coverage they considered inappropriate or facing substantial financial penalties.

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"Business owners who are objecting to the mandate are not objecting to people using contraceptives, but that they have to arrange for and pay for it," White, a lawyer with the American Center for Law and Justice, said in a phone interview. "The federal government shouldn't tell business owners they have to contract to buy what they see as immoral services and goods."

Judges Joel Flaum and Diane Sykes comprised the 7th Circuit majority.

High court declines to block contraceptives coverage in health care law

Judge Ilana Rovner dissented. She said the Kortes were "multiple steps" removed from the contraceptives services because it was their company paying for the coverage, and because it would be a worker, her doctor and the insurer involved in the decisions about the services and their funding.

The Kortes' case is expected to continue in the 7th Circuit.

Neither the 7th Circuit nor Sotomayor ruled on the merits of their respective cases. The legal standard for obtaining an injunction from the Supreme Court is much higher.

The case is Korte et al v. Sebelius, 7th U.S. Circuit Court of Appeals, No. 12-3841.

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The health insurance industry presented itself as a key ally of President Barack Obama’s health care law while at the same time making hefty contributions to members of Congress who are trying to get rid of it, according to contribution records.

Between January of 2007 and August of 2012, the political action committees of the 11 largest health insurance companies and their primary trade group gave $10.2 million to federal politicians, with nearly two-thirds of the total going to Republicans who oppose the law or support its repeal, according to the Center for Public Integrity’s analysis of Federal Election Commission filings.

The 11 top companies, according to the Fortune 500 list, controlled 35 percent of the industry in 2011, according to data from the National Association of Insurance Commissioners. The top industry trade group is America’s Health Insurance Plans.

Much of the money rolled in as health insurance industry leaders lauded the Democrats’ reform efforts.

“We are ready to be accountable to these [new] rules,” Karen Ignagni, AHIP’s president and CEO told the Senate Finance Committee in May 2009, roughly almost a year before Obama’s landmark legislation was signed into law. And when a month after Obama’s Affordable Care Act became law in March 2010, Ignagni said her organization was “strongly committed” to [its] “successful implementation.”

Likewise, Ron Williams, then chairman and CEO of Aetna, the country’s fifth-largest health insurance company, also spoke favorably about the bill — at first.

“I believe that President Obama and this Congress have charted a course of change,” Williams said in a June 2009 statement. “I want to make clear that we too are committed to expanding access, controlling costs and improving the quality and value of care people receive.”

But Williams, who left Aetna in April 2011, has since changed his mind. This past June, Williams penned a Wall Street Journal op-ed calling for health care reform at the state level and criticizing the federal law’s mandate.

Cantor, Ryan among top beneficiaries
House Majority Leader Eric Cantor, R-Va., ranks as the top recipient of PAC money from the top insurers since 2007, according to the Center’s analysis. Cantor, a tea party favorite and one of the law’s most vocal critics, has received about $258,000 from AHIP and the top industry PACs.

In January 2011, Cantor introduced the “Repealing the Job-Killing Health Care Law Act,” the first of 33 repeal efforts that have reached the House floor.

That same year, Aetna, Humana, UnitedHealth Group and WellPoint — which together control 28 percent of the health insurance market — maxed out to Cantor, giving $10,000 apiece to his campaign committee. That doesn’t include additional sums that went into the congressman’s leadership PAC.

Behind Cantor, Rep. David Camp, R-Mich., ranks second in health insurance industry contributions. The chairman of the powerful House Ways and Means Committee has pulled in more than $234,000 from these PACs since 2007.

“The American people have told us they don’t want to be forced to buy health insurance that they don’t want and they can’t afford,” Camp declared in February 2010. A year later, Camp sponsored a bill that would cut $11.6 billion in funding for the law.

Rep. Paul Ryan, R-Wis., now the Republican nominee for vice president Mitt Romney’s running mate, is also among the top recipients of funds from health insurance companies and a leader in House’s efforts to repeal the health care law.

The dozen PACs studied by the Center donated $187,000 to Ryan between 2007 and 2012, placing the Wisconsin congressman fourth on the list. Just this year, Ryan, who chairs the influential House Budget Committee, has sponsored two major budget plans that have called for the law’s repeal.

Other top recipients of health insurance PAC money during this period include House Speaker John Boehner ($209,500), Republican House Whip Kevin McCarthy of California ($149,700), Sen. Orrin Hatch, R-Utah, who is the ranking GOP member of the Senate Finance Committee ($151,500), and Senate Finance Committee Chairman Max Baucus, D-Mont. ($142,400).

Why back the repeal?
So if the health insurance industry was in favor of key parts of the law, why is it supporting members of Congress who are so bent on killing it?

Part of the reason is that the legislation’s centerpiece, the requirement that almost everyone sign up for health insurance or pay a penalty, is expected to benefit the health insurance industry. Democrats supported the provision; Republicans despise it — despite its origins as a conservative idea.

More than a decade ago, an individual health insurance mandate was proposed by Stuart M. Butler of the conservative Heritage Foundation. During the 1993 health care debate, Republican lawmakers supported legislation that included an individual mandate. And the idea was endorsed by Republican Mitt Romney during his reforms as governor of Massachusetts.

During Congress' recent debate over health care reform, the industry was "playing supporters because there is nothing the health insurance industry wanted more than an individual mandate to force people to buy their product," says Carmen Balber, who monitors health policy at the nonprofit Consumer Watchdog.

At the time the reform law passed, the Democratic Party controlled the White House and both houses of Congress. By supporting the law, the industry was able to stay in the game on a very complex piece of legislation.

While the industry certainly did support parts of the law — such as the individual mandate — there were plenty of provisions it did not like and would like to see repealed.

AHIP and WellPoint — the industry’s top PAC contributor — did not reply to the Center’s telephone or email inquiries requesting comment. Representatives from Aetna, Amerigroup, Cigna and Humana declined to comment for this story.

Rome said he suspects the industry views support of Republican candidates — who will undoubtedly vote for deregulation — as a long-term investment.

For example, under the new law, insurance companies must spend at least 80 cents of every premium dollar on medical care for individual and small business policyholders — and 85 cents for large groups. That’s a provision the industry would like to see repealed.

Insurers must send policyholders or their employers rebate checks if the ratio drops below those levels.

In recent statements, AHIP claims the provision, known as the “medical loss ratio requirement,” could inhibit innovation and drive up administrative costs because of new reporting requirements.

Indeed, AHIP has lobbied extensively for a new bill that — according to Consumer Watchdog’s Balber — “would effectively gut the medical loss ratio requirement,” by allowing insurance companies to include broker compensation as a medical care cost in the ratio.

This legislation, introduced as H.R. 1206, is sponsored by Rep. Mike Rogers, R-Mich., and was forwarded to the House Energy and Commerce Committee on Sept. 11. Rogers ranks 19th on the Center’s list of top health insurance beneficiaries, receiving $90,500 over the nearly six-year period. AHIP supports Rogers' bill, as do several trade associations representing brokers and agents, claiming broker salaries commissions are not necessarily administrative costs, but rather a “human resource” expense because independent brokers and agents help patients select plans.

But to Balber, factoring insurance broker salaries as a medical cost — and thus, part of the 80 percent requirement — is “absurd.” Such a shift in premium calculation would negate the cost-cutting benefits of the medical loss ratio provision — what she considers the law’s strongest consumer protection.

Looking forward
Since the Democrats’ Affordable Care Act was signed into law, the political environment has changed dramatically.

Democrats no longer hold a filibuster-proof majority in the Senate, the House is controlled by Republicans and the president is in a tight race for re-election.

Despite his party’s unified attack on the health care law, Romney, whose own health insurance reforms in Massachusetts were a model for Obama’s plan, has recently hinted at willingness to compromise on some of its politically popular elements.

“Well, I'm not getting rid of all of health care reform,” Romney, the GOP's presidential nominee, said in a Sept.9 interview with David Gregory on NBC’s Meet the Press.

While the individual mandate is widely viewed as unpopular, the opposite is true for many provisions such as the prohibition on companies refusing to cover patients with pre-existing conditions, the closing of the Medicare Part D prescription drug “donut hole” and the option for young adults to stay on their parent’s plan until age 26. According to Bob Laszewski, an insurance industry consultant, a Romney administration would not be able to secure enough votes in the Senate to repeal the law, even if it wanted to.

A more realistic legislative outcome is that congressional Republicans will attempt to defund the law through budget reconciliation rules — a scenario that would likely hurt insurance company balance sheets, he said.

GOP defunding efforts would leave insurance companies subject to the law’s politically popular insurance regulations — like covering patients with pre-existing conditions — but without government subsidies that are provided in some parts of the plan.

“If Romney wins, I think you’re going to see the insurance industry very concerned about Republicans trying to choke health care reform,” Laszewski said.

Andrea Fuller, Lydia Mulvaney and Michael Beckel contributed to this report.

The Center for Public Integrity is a non-profit, non-partisan investigative news organization in Washington, DC.

 For more of its stories on this topic, please go to http://www.publicintegrity.org/politics/consider-source.

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Pablo Martinez Monsivais / AP

President Barack Obama, accompanied by Sandra Fluke, waves at a campaign event at the University of Colorado Auraria Events Center on Wednesday. Fluke is a Georgetown law student who inadvertently gained notoriety when talk show host Rush Limbaugh spoke disparagingly of her testimony before Congress on the issue of contraception and insurance coverage.

DENVER, Colo. – Seeking to rally female voters who helped push him to victory in 2008, President Barack Obama warned a crowd of mostly women in Colorado that Mitt Romney would slash the benefits they received last week under the new health care law.

Standing in front of a big sign that read, “WOMEN’S HEALTH SECURITY” to emphasize the day’s message, the president touted recently-implemented measures in the health care law requiring all insurance companies to provide free preventive care for women. The Obama administration reports that 47 million women will receive free contraception, well-woman visits, breastfeeding supplies and family planning counseling.

Obama said Romney would slash those benefits on the first day of his presidency.

“He said he would take the affordable care act and kill it dead -- on the first day of his presidency. Kill it dead,” he said as the crowd of 4,000 at the Auraria Event Center booed.

Reviving a debate over contraceptive coverage from earlier this year in which both parties accused the other of waging a “war on women,” the president said that Romney would let employers decide whether or not to offer women’s health services like contraceptives.

“I don’t think your boss should get to control the health care you get. I don’t think insurance companies should control the care that you get. I don’t think politicians should control the care that you get. I think there’s one person to make these decisions on health care and that is you,” he said.

Obama enlisted a familiar face from the contraception debate to introduce him in Denver: Sandra Fluke, a Georgetown law student and activist who testified on Capitol Hill about her school not covering birth control and became the face of the Democratic side of the issue after she was called a “slut” and “prostitute” by conservative radio host Rush Limbaugh.

Fluke praised the president for “defending my right to speak without being attacked. Mr. Romney could only say those weren’t the words he would have chosen. Well, Mr. Romney, you're not going to be the candidate we choose,” she said.

Obama’s two-day swing through Colorado, which he won by nine points in 2008, comes as a new Quinnipiac/New York Times/CBS poll shows him trailing Romney in Colorado by five points, 50-45.

While Obama campaign officials stress that they always believed Colorado would be a competitive state, the president underscored how important he believes the Centennial State is to his re-election when he responded to the crowd’s chant of “four more years!”

“If we win Colorado, I’ll get four more years!” he said.

Obama continues his four-city Colorado trip later tonight in Grand Junction.

Earlier Wednesday, before the president's speech, the Romney campaign sent out figures showing high unemployment rates among women during Obama's tenure, as well as a statement from campaign spokesperson Amanda Henneberg.

“No false, recycled attacks can distract from the fact that President Obama’s four years in office haven’t been kind to women," Henneberg said in the statement. "Hundreds of thousands of women have lost their jobs, poverty among women is highest in nearly two decades, and half of recent graduates can’t find a good job. Middle-class families have struggled in the Obama economy, and Mitt Romney has a plan to strengthen the middle class and get our country back on the right track.”

www.farrahsoudani.com

The Farrah Soudani Fund website was set up by her family to raise money for a disability trust for the woman who was wounded in the Aurora, Colo. theater shooting.

In the days following the deadly shootings in Aurora, Colo., two sites soliciting donations were created for Farrah Soudani, a 22-year-old whose spleen and kidney were removed after she and dozens of others were shot in a movie theater during the midnight showing of “The Dark Knight Rises.”

The first was set up on gofundme.com by a friend of Soudani’s mother who pledged that all the money would go to Soudani. By Thursday evening, the site had raised more than $143,000.

But Soudani’s family on her dad's side worried about where that money would end up. They didn’t know this woman well, her brother Jordan Soudani said. Marty Soudani, a business owner, argued that a disability trust should be set up for his younger cousin, to protect her from creditors.

“We don’t know if that fund is going to go 100 percent to her,” Marty Soudani said. A trust would be more secure, he said; if Soudani, who does not have health insurance, went bankrupt, he said, creditors wouldn’t be able to touch the trust money, which could help to cover long-term care.

Woman survives theater shooting thanks to her boyfriend's father

The Soudani family, which has raised about $10,000 for the Farrah Soudani Fund, has asked those handling the gofundme.com site to transfer the donations to the trust. But so far, the family said, they have remained noncommittal. Those handling the gofundme.com site did not reply to a message from NBC News sent through the donation site.

Victoria Albright, who manages the site, responded to skeptics in an online post: “I will see that these funds are never manipulated, or land in the wrong hands. This is ALL about Farrah and her recovery. Promise!”

“We’re not saying they’re thieves,” Marty Soudani said, “but they’re not working with the family.”

Soudani isn’t alone in being wary of outsiders’ zeal to raise money.

Ken Berger — president and CEO of Charity Navigator, a non-profit charity watchdog group — told NBC’s Technolog that he advises caution.

gofundme.com

A website set up by a friend of Soudani's mother has raised more than $143,000.

"Disasters are a time when people run into a situation where they, to some degree, are flying blind because the charities they know — the ones they typically give to — may not be providing services in the area,” Berger said. “So it's a time that scammers are likely to prey on people.”

Anticipating this, Colorado Gov. John Hickenlooper encouraged people to give through GivingFirst.org, which raised nearly $2 million by Thursday. There, donors can choose a specific nonprofit – Aurora Mental Health Center or Denver Center for Crime Victims, for example – or ask that their money go wherever deemed necessary. The University of Colorado Hospital Foundation has also solicited donations for a 7/20 Victims Fund to help cover the care of those shot in the early hours of July 20.

Still, for those whose loved ones remain hospitalized, their bills soaring, raising money through sites such as PayPal or wepay.com has immediate appeal. A fund for Caleb Medley, who was in a medically induced coma while his wife gave birth to their son, Hugo, had $330,000 by Thursday evening. Medley does not have health insurance, according to the site.

The site says Medley and his wife “need help covering their medical bills (which will no doubt be in the hundreds of thousands if not millions of dollars), cost of living, baby supplies, and maybe even a college fund for Hugo! They need our help!”

But officials warn that a significant influx of cash could mean the victims are no longer eligible for certain social services, such as Medicaid, which covers long-term care for low-income people.   

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“If you give to an individual, it’s not tax deductible and it can affect the long-term security of those folks,” said Dana Rinderknecht, manager of online giving at GivingFirst.org. “They can lose some services.”

Rachel Reiter, a spokeswoman for the Colorado Department of Health Care Policy and Financing, emphasized that Medicaid is determined on a case-by-case basis but said income is one of the factors considered.

Reiter said state workers are helping families figure out if they qualify for aid, particularly if they have long-term needs. Medicaid helps to cover the medical care of families, children, pregnant women and people with disabilities -- particularly those with long-term care needs.  

“Giving through a nonprofit is strongly encouraged,” Reiter said in an e-mail. “For individuals who are disabled, excess funds may be placed in a Disability Trust and the funds would not be counted against the individual. We have staff working with the hospitals and families where this may be an option.”

Christine Handel, a Soudani family friend who helped to create the trust site, described raising money in the wake of such a tragedy as “navigating a minefield.”

“There’s no road map for this when these things happen,” Handel said. “It’s not that people have bad intentions – they don’t have knowledge. We don’t want Farrah to worry about tax season next year. She needs to go to her appointments and see her doctors and get better.”  

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Most social media users approve of the Supreme Court's health care ruling last week but believe it will help Republicans in the November election, according to msnbc.com's computer-assisted analysis of tens of thousands of posts on Twitter and Facebook.

M. Alex Johnson is a reporter for msnbc.com. Follow him on Twitter and Facebook.

The court upheld nearly all of the Patient Protection and Affordable Care Act on a 5-4 vote Thursday. The consensus in news reports and among political pundits was that the ruling was a major victory for President Barack Obama.

But among people who use social networking sites, 56 percent of those who stated a clear opinion on the decision's political impact said they thought it was more likely to energize Republican voters in November. Forty-four percent said it was likely to be more helpful for Democrats.

(Msnbc.com analyzed 175,000 Twitter and Facebook posts mentioning the ruling from midday Thursday through midday Monday. The analysis uses a tool called ForSight, a data platform developed by Crimson Hexagon Inc., which is used by many media and research organizations to gauge public opinion in new media. Crimson Hexagon reports a 3-percentage-point margin of sampling error for this type of online sentiment analysis.)

More social media analysis from NBCPolitics.com

Overall, 60 percent of online commenters approved of the decision, with many of them telling stories about how it would have an immediate impact on their families.

Supreme Court upholds health care law
Health care ruling could leave poorest Americans at greatest risk

Writing on Facebook, Cathy Weller of Cocoa Beach, Fla., described herself as "a fiscal conservative, libertarian leaning, social progressive." She wrote of losing her health insurance when she lost her job and the difficulty she had insuring herself because of her pre-existing condition — cancer:

All of a sudden I found myself researching health insurance options. Imagine my surprise to find there were none. None. Not a few expensive ones, but none. It didn't matter if I was willing to pay $10,000 a month for health insurance, it was just not available to me, anywhere for any amount of money. This was the first time I personally came up against the issue of health insurance availability having worked constantly up to that point and always having employer offered insurance.

Of opponents of the act, Weller wrote: "I wonder at their sense of security. Do they really imagine themselves to be invulnerable to what so many fellow citizens are going through?"

Nearly a quarter of those supporting the decision stressed its impact on ending what they see as a bias against women in the current health care system.

Among them was Lisa Kitinoja of Eugene, Ore., who administers a nonprofit organization:

Twitter.com

Many opponents complained that the act would make health care more expensive, including Darren Perkins of Kansas City, Mo.:

Twitter.com

Others saw it as unconstitutionally giving the federal government too much control over people's lives, like Andrew Hastings, an engineer in San Diego:

Facebook.com

The 60 percent-to-40 percent split among social media users in favor of the ruling runs counter to public opinion surveys, which generally indicate that a slight majority opposes the health care act. A Reuters/Ipsos poll released Sunday put support at 48 percent.

The social media results, however, could be a reflection of rising support since the Supreme Court ruling. The Reuters/Ipsos poll, for example, found that before Thursday, support was only 43 percent before rising to 48 percent. (Support in msnbc.com's analysis also showed support trending up since the ruling, hitting 62 percent Monday.)

They also may be explained by the demographics of the social media audience. The Pew Internet & American Life Project, which uses ForSight in its statistical analysis of social media, reported in March that people who identify themselves as liberal are more likely to use social networking sites than are people who self identify as conservatives.

Even so, commenters concluded that Republicans would benefit from the ruling politically more than Democrats, by 56 percent to 44 percent.

Mike Wasylik, a lawyer in Tampa, Fla., wrote:

Twitter.com

Chris Twining, a computer consultant in Wildomar, Calif., explained on Facebook:

Facebook.com

And Michael Gorka of Newport News, Va., said:

Facebook.com

Real-world evidence may support that analysis — Republican presidential candidate Mitt Romney's campaign reported that Friday was its biggest fundraising day from individual donors so far.

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Florida Gov. Rick Scott now says Florida will do nothing to comply with President Barack Obama's health care overhaul and will not expand its Medicaid program. The announcement is a marked changed after the governor recently said he would follow the law if it were upheld by the U.S. Supreme Court.

"Florida is not going to implement Obamacare. We are not going to expand Medicaid and we're not going to implement exchanges,'' Scott's spokesman Lane Wright told The Associated Press on Saturday. Wright stressed that the governor would work to make sure the law is repealed.

Scott told Fox News the Medicaid expansion would cost Florida taxpayers $1.9 billion a year, but it's unclear how he arrived at that figure.

See the original report at NBCMiami.com

Scott said the state will not expand the Medicaid program in order to lower the number of uninsured residents, nor will Florida set up a state-run health exchange, a marketplace where people who need insurance policies could shop for them.

"We care about having a health care safety net for the vulnerable Floridians, but this is an expansion that just doesn't make any sense,'' he told Fox host Greta Van Susteren.

Scott has gone back and forth on the issue after the U.S. Supreme Court ruled Thursday that Congress cannot withhold federal Medicaid funding from states that opt out of a requirement in the overhaul to expand coverage to those just above the poverty line.

On the day of the ruling Scott was cautious about the expansion, saying he wanted to read the ruling first. Then during an interview Friday morning on a Jacksonville radio station, Scott said it was unlikely he would go along with the expansion because of the potential cost to the state.

But the governor told the Tampa Bay Times later in the day that he was still evaluating the ruling and would come up with a plan within a few weeks.

Scott, the former CEO of a hospital chain, has been a vocal critic of the health care overhaul from the start. He made his first foray into politics by forming a group called Conservatives for Patients Rights that ran television ads criticizing the proposal before it was adopted by Congress.

Scott has also complained about the growing cost of Medicaid, the $21 billion safety net program that primarily aids the poor but also picks up nursing home bills for senior citizens. The governor backed a push by the Republican-controlled Legislature to shift Medicaid patients into managed care programs, a move that is still awaiting federal approval.

Scott has rejected federal money in the past, most notably $2.4 billion for high speed rail. His administration has also said no to some money attached to the Affordable Care Act.

But Scott has said yes to money associated with the federal stimulus program and he has changed some of the positions he advocated during his run for governor. Scott also must weigh the political calculations of saying no to Medicaid because of tight budgets, while it is likely he will continue to push for substantial tax cuts between now and his re-election campaign in 2014.

According to Census data released last year, Florida had the nation's third-highest rate of residents without health insurance during the past three years.

President Obama's health care law called for states in 2014 to expand Medicaid eligibility to those making up to 133 percent of the poverty level, or $29,326 for a family of four. While estimates vary, the Florida Agency for Health Care Administration has concluded that as many as 1.95 million more people would join Medicaid and other state-subsidized health insurance programs over the next five years.

Most of the cost, running into the billions, would be absorbed by the federal government. The Medicaid expansion would not cost the state anything until 2017 — although AHCA estimates that changes to other state-subsidized programs would require state money starting in 2014. AHCA estimates that the overall cost to the state would be $2.4 billion between 2013 and 2018 with the federal government picking up nearly $26 billion.

But other groups analyzing the potential changes contend that state officials have ``hyper-inflated'' the potential costs because they assume too many people will enroll.

The ultimate choice, however, won't be Scott's alone. It will also be decided by the Legislature.

Updated at 7:04 p.m. ET: Now that the Supreme Court has upheld President Barack Obama's health care initiative, will Congress have to rewrite it from scratch?

M. Alex Johnson is a reporter for msnbc.com. Follow him on Twitter and Facebook.

It's not a paradoxical question. The court signed off on nearly all of the Patient Protection and Affordable Care Act, but it struck down one provision, and in doing so — whether it knew it or not — it may have put the poorest Americans at the greatest risk of being left without any health insurance.

Chief Justice John Roberts said as part of the 5-4 decision that states can't be penalized for refusing to join the law's expansion of Medicaid eligibility. Health law experts said that had the practical effect of flipping an all but mandatory program into one a state can choose not to join.

Here's the problem: The ACA creates state health insurance "exchanges," providing tax credits to eligible residents to buy affordable, state-certified health insurance. But the poorest Americans aren't in that eligible pool, because the law assumes they'll be covered by the expansion of Medicaid, which is no longer a given. 

In states that reject the expansion, poor residents could be left without either form of coverage — as many as 15 million if all 50 states opt out, a circumstance that former Medicaid director Donald Berwick said was highly unlikely.

The White House didn't address the issue in a long Q&A it issued on the court's decision. The statement touted every provision of the act but one: Medicaid expansion.

Medicaid currently covers only some low-income people, primarily parents with children, pregnant women, people with severe disabilities and senior citizens. Adults without disabilities or children, in other words, aren't generally covered. That's the group the Medicaid expansion was supposed to help the most.

Supreme Court upholds health care mandate

Obama calls ruling victory for US; Romney vows to repeal

After the ruling: Lots left to do on health reform

Full ruling from the court

If their states opt out, young working adults below the poverty line could be in a Catch-22, because "they may not get Medicaid, and they may not be eligible to purchase insurance through the exchange," said Christina S. Ho of the Rutgers University School of Law, who was a member of President Bill Clinton's Domestic Policy Council. 

It works this way:

The insurance tax credits are targeted at people with incomes between 100 percent and 400 percent of the poverty line as determined by the U.S. Census Bureau. Congress sought to compel the states to cover everyone under the line through Medicaid.

The federal government promised to fully cover all expenses for the expanded coverage before eventually pulling back to cover 90 percent after a few years. The states would have to pick up the extra 10 percent eventually.

States aren't required to take part, but if they don't, the law as enacted would have turned off the flow of all Medicaid funding from Washington. 

That enforcement mechanism is what the court invalidated Thursday, meaning there's no penalty for a state that says, "Thanks, but no thanks."

Twitter reactions to the ruling

Because states haven't had time to consider yet whether they will opt in or out. it's difficult to say how many people could be affected. 

But about half of the nearly 50 million uninsured Americans have incomes below the new eligibility thresholds, according to the latest report, in October, from the Kaiser Commission on Medicaid and the Uninsured. And about 6 in 10 of them are adults without dependent children — the primary beneficiaries of the program's expansion.

If you do the math, roughly 15 million Americans could be in the newly created gray area. In 2010, when the act was passed, the Commonwealth Fund, an independent health care policy foundation, similarly calculated that the Medicaid expansion would benefit 12 million of the 15 million uninsured Americans under the poverty line. 

Donald Berwick, former head of the Centers for Medicare and Medicaid Services, which administers the two programs, said few states were likely to take that risk.

"Those people are still living in your state, They're still poor. They're going to come to your emergency room. They're going to be operated on, and they're going to have diseases that get worse, and you're going to have to pay for that. That will come from the state — free care pools and charity in the state," Berwick said in an interview on MSNBC-TV. 

"I think what's going to happen is the states are going to be under pressure from providers of care who say: 'Why are you leaving this money on the table? Let's join in with the federal dollars.'"

But Judy Solomon, vice president for health policy at the nonpartisan Center on Budget and Policy Priorities, agreed with Ho that the decision means low-income adults could lose the promise of Medicaid coverage "even while people with somewhat higher incomes will be eligible for premium tax credits." 

Writing on the center's policy blog, Solomon said: "The poorest adults — primarily parents and other adults working for low wages — will be left out in the cold."

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