Raleigh, N.C. — When President Barack Obama and Democrats in Congress authored the 2010 Affordable Care Act, they required that all states expand their Medicaid programs for the poor and disabled. The idea was that they would close a gap between those eligible under current rules for Medicaid and those who could afford to buy coverage on newly constructed health exchanges.

Gov. Bev Perdue will have to will have to decide how the state might handle those health exchanges in the coming weeks. But it will be up to legislative budget writers to decide whether Medicaid will expand. 

But when the U.S. Supreme Court handed Obama what was hailed as a victory for the health insurance law, the justices dealt the administration one setback. The court ruled that states would have the option of expanding their program but couldn't be forced to do so. 

Adam Searing, a health policy expert based in North Carolina, says this could leave some families betwixt and between, since they won't be able to afford coverage even with subsidies available to those in the new health exchanges.

"They will not be provided any help when people above them in the income scale will be," Searing said.

But legislative Republicans may be unwilling to expand Medicaid. Although the federal government will initially bear the cost of expansion, states will eventually have to pick up part of the tab.

"There's a potential downside risk there in the range of several hundred million dollars," said Rep. Nelson Dollar, R-Wake, who has been a key player in health and budget policy at the General Assembly. Future versions of the U.S. Congress could push much of the cost for the expanded Medicaid coverage down to the states. 

"I think we're going to have to hash that out," Dollar said.