By now, you've probably been inundated with nonstop coverage of the Supreme Court's decision to uphold the Affordable Care Act in its entirety yesterday, while leaving some wiggle room for states to opt out of the ACA's Medicaid expansion. For hospitals and other health care providers, the policy focus will begin to shift in the coming weeks and months away from Washington, D.C., to their respective state capitals, as governors and legislators decide how to proceed on the creation of health insurance exchanges and whether or not to participate in Medicaid expansion.

While the federal government would fully fund the first three years of Medicaid expansion, from 2014 to 2017, the Supreme Court ruling bars the federal government from withholding existing Medicaid funds from states that don't participate in that aspect of the ACA.

"There is a lot to learn, in particular, about whether states opt out or not," American Hospital Association President and CEO Rich Umbdenstock said during a conference call with reporters yesterday.

In states that don't join the Medicaid expansion, one key population that might be impacted, Umbdenstock noted, are uninsured citizens earning between 100 and 133 percent of federal poverty guidelines. Those individuals were set to be covered in the Medicaid expansion; uninsured citizens between 133 and 400 percent of the poverty guidelines are eligible instead for their state's health insurance exchanges.

"What happens to people [between 100 and 133 percent of federal poverty guidelines]?" Umbdenstock asked. "We don't know."

Initial reports indicate that political leaders from states including Mississippi, Missouri and Wisconsin are unlikely to proceed with Medicaid expansion.

Regardless of their intentions to get the ball rolling, many states face an uphill battle to meet a Nov. 16 deadline for creating an online health insurance exchange, or instead partner with the federal government on an exchange. That's the situation in Illinois, the Springfield Journal-Register reported shortly before the ruling.

Other states appear to be more prepared for the exchanges: in West Virginia, the Charleston Gazette reported that leaders of that state's House and Senate expect to move forward with both the expansion of Medicaid and the creation of the ACA's health insurance exchanges. The insurance exchanges could cover up to 250,000 state residents, the Gazette reported.

"We already have some of the infrastructure in place to move forward," West Virginia Senate Health and Human Resources Chairman Ron Stollings, D-Boone, told the Gazette.

Email me your thoughts on the Supreme Court decision, and I may feature them in an upcoming column.