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If I understand the structure right, without the Medicare taxes on the states, and without taxes passed by the House, this thing is dead as Ronnie James Dio.

I don't think that's correct, LS.

The dark heart of ObamaCare is that it requires (essentially) that all health insurance in the United States must eventually conform to what the federal government decides it should cover.

In other words, for the vast majority of people, the federal government will make the decision as to whether or not a particular treatment will be allowed to be paid.

If someone comes up with a breakthrough treatment for a particular condition, it is not enough to convince doctors or even insurance companies of it. One will have to go on bended knee to a stupid federal bureaucrat, and convince him or her to allow it to be paid as an accepted treatment.

Naturally these will be political decisions, especially whenever the Left is in charge of the bureaucracy. And of course "pay to play" will be the order of the day as companies that provide medical devices or other treatments will need to curry favor with the politicians in order to ensure that the government will allow insurance policies to pay for that particular treatment.

And because a Soviet-style government bureaucracy is about the least efficient approach possible to allocating health resources, there will be massive waste and fraud and uncontrollable costs will lead to rationing of treatments and attempts at federal control of all lifestyle decisions in the name of managing healthcare costs.

My understanding is that all of that goes ahead even if states decline to accept the additional Medicaid funding to cover people up to 130% of the poverty line.