It is more than that states will choose not to participate in Obamacare’s extension of Medicaid eligibility. Small population state like South Dakota currently have only a few health insurance providers because of their small markets. Remember that FEDERAL law prohibits health insurance companies from offering coverage across state lines except in some limited cases with waivers for multi-state companies. With the skyrocketing costs of insurance inherent with Obamacre, health insurance companies will likely stop offering policies in low population states because there are insufficient numbers of insured people to spread the now higher costs.
Exactly, the rates will have to go up or the insurance companies will have to stop offering insurance in some markets. It is a fine mess that Justice Roberts created with his activist rewrite of the law - with many unintended (?) or unforseen consequences.
See Health care ruling could leave poorest Americans at greatest risk - FR / MSNBC, 2012 June 28, by Alex Johnson.