The Supreme Court decision may have as far reaching effects as the election of Lincoln to the presidency. From the New Republic is this account of how Texas may block the ACA’s intent to move the money allocated by the federal government for indigent care from getting to the folks taking care of poor people:

The Texas medical safety net consists of geographical districts, each with its own set of public or quasi-public hospitals and clinics. These districts have their own taxing authority. The more care they must provide to the uninsured for free, the higher they have to push those taxes. Private hospitals provide charity care, too, but they also have to make up for the losses—in part, by charging higher premiums to private insurers. In these respects, as Rick Ungar points out in Forbes, one consequence of turning down federal Medicaid dollars is higher costs, in the form of property taxes and private insurance premiums, for middle-class Texans.

Yes, these hospitals and hospital districts already bear a heavy financial burden for the uninsured, so middle-class Texans are, in a sense, already paying for these costs. But the Affordable Care Act also reduces some of the direct federal funding these providers presently receive. This is very much by design: At least in the current environment, it’s arguably more efficient, and more consumer-friendly, to provide individuals with insurance than to simply throw money at hospitals.

So here is the view from Parkland Hospital:
[Per] Ron Anderson, who for 29 years was the president and Chief Executive Officer of Parkland Hospital, the largest safety net provider in Dallas. “This would not just be a net loss for Parkland,” Anderson said. “It’d be a net loss for every provider in Dallas County. In our area, it would cost us hundreds of millions of dollars and destablize the safety net.” In the past, Anderson noted, local hospitals and officials were able to use creative financing, to squeeze extra money out of existing federal and state funding. “But I think we’re out of rabbits in that hat. If the state refuses to accept this, I think we’ll be pretty wounded – it would be devastating for individual patients, communities, and local taxpayers.”
There is speculation that this is posturing and when the time comes the legislators and governors will “do the right thing.” It is important for those of us involved in the care of the poor to educate the legislators that providing funding to the poor via the new Medicaid is important. Indeed, it may even exceed the political reward for turning it down to prove a point.
We can be encouraged that our elected officials might follow the counsel of our local publication, the Lagniappe. From yesterday’s political column:
“I think the American citizens ought to press their state governors and legislatures just to nullify the law — just to plain nullify it and say, ‘The citizens of such-and-such-a state don’t have to obey Obamacare because it’s unconstitutional, regardless of what the Supreme Court says,’” Walter Williams said.

One of the first states to use this power could be Alabama — with Republicans in almost every important seat of power in both the executive and legislative branches, the state of Alabama could take a shot at this. Sure, it wouldn’t be popular on the pages of The New York Times or on MSNBC, but it might set a trend with other states and show just how unpopular the law is. The fallback: Well yes, nullification did lead to the Civil War. But that was over something much different.
Worked well in Brown v Board of Education as well…