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States are not allowed to experiment with their Medicaid programs without receiving waivers from the federal government, but the feds have been slow to issue decisions. "As we approach the beginning of legislative sessions in many states," Crippen says, "governors are faced with making tough decisions without adequate information about programs and their funding."

Oregon is a case in point. Democratic Governor John Kitzhaber has had what he calls promising talks with the U.S. Department of Health and Human Services about a groundbreaking new health program the state is banking on to cut Medicaid spending this year.

By setting up so-called "coordinated care organizations" as the front door for patients, the state aims to abandon the impersonal and fragmented way most people receive health services today. In addition to improving health, the new system is expected to cut costs. But Kitzhaber worries that if federal approval doesn't come early this year, those savings may not materialize.

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Issues before the Supreme Court

Starting March 26, the U.S. Supreme Court will devote five-and-a-half hours to hearing oral arguments in a case against the Affordable Care Act brought by 26 states and the National Federation of Independent Businesses. A decision is expected in late June. A range of outcomes are possible, each with a different potential impact on states. The entire law could be overturned or upheld --- or something in between. It's also possible that the Justices could decide to put the case off for a few more years.

Here are the four key issues before the court.

'Anti-injunction Act'

Under the Affordable Care Act, anyone who does not sign up for a health insurance policy would be penalized under the federal tax code. As a result, some argue the 1867 "Anti-Injunction Act" applies. According to the law, the courts are barred from striking down any tax law until someone has actually had to pay the tax. If the high court agrees that the law applies in this case, a final decision on the substance of the case would likely be postponed until 2015.

The 'individual mandate'

At the heart of the health law is a requirement that nearly everyone have health insurance. Opponents say Congress exceeded its power under the Constitution by requiring people to purchase something they don't want to buy. The Obama administration argues that anyone who decides not to purchase insurance puts everyone else at risk of having to pay for their care.

Severability

If the court overturns the individual mandate, the next question is whether other parts of the Affordable Care Act can remain standing --- in other words, whether the mandate is "severable" from the rest of the law. Opponents of the law argue that a ruling against the individual mandate would make key parts of the rest of the law unenforceable. For example, they argue that insurance companies could not be required to cover sick people if healthy people are not required to pay into the risk pool. But the Obama administration counters that the rest of the law stands on its own with or without the individual mandate.

Medicaid expansion

Some states have argued that the federal law's required expansion of Medicaid to some 17 million more people violates the balance of authority and