In some states, such as Louisiana, home to Gov. Bobby Jindal, Republicans are continuing their fight against President Obama’s Affordable Care Act. This pushback, which has the support of some in Congress, including Minnesota Rep. Michele Bachmann, prevents some of the 49 million Americans without health care from reaching a doctor’s office and avoiding costly emergency room visits for easily treatable conditions.

The law championed by President Obama and enacted by Congress nearly three years ago includes a dramatic expansion of Medicaid. In place of the patchwork of eligibility levels now set by each state, one standard is to prevail everywhere: Individuals with annual incomes up to 133 percent of the federal poverty line — currently, $14,856 or less — are supposed to be able to enroll.

Were the Obamacare expansion enacted today, some 17 million people would gain the right to coverage under Medicaid or the Children’s Health Insurance program, according to the Congressional Budget Office. Laura Johnson would be among them. But the policy does not take effect until 2014. And in several states, including Louisiana, it increasingly appears the policy may not take effect at all.

This is in large part because of a landmark Supreme Court decision earlier this year. The court affirmed Obamacare’s key mechanism — the authority of the federal government to mandate that people buy some form of health insurance or pay penalties — but the justices overturned another crucial provision: They decreed that states have the right to opt out of the Medicaid expansion, a step that would deprive people like Johnson of care.