The message from the Supreme Court’s King v. Burwell case yesterday was pretty simple for people interested in following the Medicaid expansion debate in the states. Now that it’s clear access to affordable coverage is here to stay for people above the poverty line, states that haven’t taken the Affordable Care Act’s Medicaid funding to extend coverage to the poor should reevaluate that resistance.

Why? Despite the Court’s 2012 decision invalidating the ACA’s requirement that all states expand Medicaid, a majority of states nevertheless have already accepted the federal Medicaid funding to extend coverage. And discussion continues in states from Alaska to Louisiana about moving towards coverage for people under the federal poverty level, including use of alternative state plans for the available Medicaid dollars. The King case will encourage more state movement and not just by removing the “uncertain insurance market” excuse for delaying Medicaid expansion many politicians have been using to avoid addressing the Medicaid issue.

King makes clear that:

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.  [King v. Burwell, 576 U.S. ___ (2015].

The decision gave more certainty to insurance markets (and skyrocketing health insurance industry stocks), more certainty to states about coverage for millions of their own residents and more political certainty that the ACA is now a permanent part of the health insurance landscape. As more than one commentator observed yesterday, improvements and changes to the law are inevitable but going back on its central premise that health coverage for all Americans is a right and not a privilege is simply not going to happen. After all, ACA opponents now are careful to talk of “repeal and replace,” and not just “repeal.”

The passionate debate around Medicaid in the last few months in both Tennessee and Florida has made this point as well. Even in these states, opponents of the alternative plans for Medicaid expansion that generated so much debate were generally loath to express the sentiment that there were just some people who didn’t deserve health coverage and looked to other reasons for their opposition.

With the King decision announced, that excuse for failing to address the Medicaid issue is gone.  What’s left? Another popular excuse is to say Medicaid is not as good of coverage as private insurance. Putting aside for a minute that private insurance companies in a majority of states often run either all or portions of state Medicaid programs currently, new research by the Commonwealth Fund sheds light on this particular roadblock. Researchers looked at access to doctors, other primary care providers and specialists for both people on Medicaid and people on private health plans in multiple states. The results can be summed up in one sentence:

The survey findings suggest that Medicaid coverage provides access to care that in most aspects is comparable to private insurance.

A chart provides an even closer look. Unsurprisingly, people on Medicaid have better access than people without health insurance. But on measures from appointments to quality of care and specialist access, people with Medicaid coverage report statistically the same results as people covered by private health plans:

Finally, another excuse frequently heard is that states “don’t have enough flexibility” in designing their own ways to use the Affordable Care Act’s Medicaid expansion funding. This simply isn’t true. Conservative state governors are racking up an impressive series of wins in getting the federal government to agree to unique state plans for use of the Medicaid dollars. In these negotiations states don’t get everything they want, but they are clearly getting enough of their ideas through to get to “yes.” In fact, the federal government is “six for six” in approving unique state plans for using the Medicaid funding under the Affordable Care Act to extend coverage to low-income people. Adults covered are typically working in jobs that don’t provide health insurance from construction to tending a cash register. These six states with approved 1115 Medicaid waivers are using enrollment in private health plans, premiums, and different copayment models to extend coverage to this new population.

The King case invalidates the latest and most major of the excuses reluctant Medicaid states have for not yet acting on accepting federal funding. Both the court decision, recent research and a willingness by the federal government to make significant concessions to states all mean the debate on Medicaid will continue to move forward.