Hey Sky,
I'm not a legal expert or anything but I did take a class on the ACA when it first came out. (My school was trying out a hybrid poly sci./ethics combo) In the class we read and discussed the text of the law as it stood then with affected experts.
Re: Question 1 - the way I understand the part of the law which relies on states participation is in reference to individual marketplaces and medicaid expansion. The citizens in the states that did not opt to expand medicaid coverage would in some cases not be eligible for as much support living in that state as compared to the coverage they may have if they live in a state that did expand medicaid. As a whole, I do not think an enormous number of people are in this situation as 32 states have expanded medicaid. The states that have not expanded are largely rural or southern states. (In case you were wondering, here is a map of the states that have/have not expanded
http://familiesusa.org/product/50-state-look-medicaid-expansion )
The other part that is the states responsibility is to create a state marketplace where individuals can go to compare and purchase health insurance if their employer does not offer it to them. The states that have decided not to do this use a federal version, so I don't see this as a huge loss to the citizens of those states.
So while there are some state by state differences in the way the ACA affects people, the differences are limited to medicaid expansion coverage and marketplace offerings.
Re: Question 2 - Medicaid access is based off of some financial criteria because we need a way of judging who can and can't afford coverage. Medicaid typically covers those below a certain income threshold only, and even if you make $2 more than that you are not eligible for medicaid. (Though you may be eligible for subsidies to help offset the cost of insurance.) This creates a gap between the people who are covered by medicaid because their income is so low, and threshold of income where virtually anyone could afford insurance. For example, let's assume the cutoff for medicaid eligibility is 15K/year for one person. If I make 25K/year, I may still be unable to afford insurance while covering my other living expenses. However, one could assume that if you make 1MM/year you can probably afford a health insurance premium. So we have a problem where there is a large number of middle class people who are struggling to pay their bills each month without the insurance bill, but they don't qualify for medicaid coverage.
If medicaid was expanded to cover anyone who couldn't afford insurance premiums it would be closer to a universal coverage system that some countries have and some people in the US have been arguing for. There are a lot of arguments for and against this type of system, and yes, the cost to taxpayers is one of them. But others include ethical concerns, resource concerns, concern for eroding capitalism, and many others.
Like I said, I'm not a legal expert, but the ACA is something I have some familiarity with. I didn't go much into the second question because I thought my political opinion would show through and I'd like to keep my SDN presence professional and non-political, but if you want a more in-depth answer that includes the political arguments from both sides, just send me a PM and I can share that with you.
Hope this helps to answer your questions!
