The federal judicial and state legislative branches hold the future of Missouri health care in their hands. How the former acts, and whether the latter changes its mind, will affect health care here for years to come.

The federal challenge to the Affordable Care Act comes via the case of King v. Burwell, which challenges health insurance subsidies in states that have not adopted an exchange. The U.S.  Supreme Court could, in one fell swoop, eliminate tax subsidies for almost 200,000 Missourians, which would result in effective premium increases of more than 300 percent, according to the Kaiser Family Foundation.

The state issue relates to the Missouri Legislature failing to expand Medicaid, as 29 states plus the District of Columbia have chosen to do in some form. Without that expansion, single taxpayers making under about $11,000, or adults in a family of four making $5,000 to  $23,000, fall in a coverage gap: no Medicaid and no tax relief for buying premiums under Obamacare. Expansion would cover that gap affecting as many as 200,000 Missourians.

And this is truly unfortunate. Because health care has a major impact on the ability of the poor, working or otherwise, to improve their station in life, something that almost all politicians claim to have as an item in their platforms.

It is, of course, really, really hard being poor and, as the recent community study of Jews in St. Louis shows, we are hardly immune from poverty. Most of us recognize that a lack of food, affordable housing and proper medical attention play major roles in making life better for this and future generations.

Lack of medical care can mean many things, including less productivity, more time off work, less stability in keeping one’s job and, ultimately, an inability to provide for family. Yet the Missouri Legislature turned down Medicaid expansion in the recent session, for the third year running, ensuring that our citizens won’t enjoy the benefits of expansions being realized in many other states.

We hear so much in this day and age about what we can and can’t collectively afford. Whether the poor, including the working poor, receive benefits seems to be something dividing the nation, the same way that taxes and size of government do. But when we consider the costs regarding health care, rarely do we pause to consider how we view our highest aspirations as a society.

This is about remembering what our parents and grandparents had to go through, as new immigrants, faced with the daunting task of surviving and making the lives of their children better than their own.

This is about parents not having to choose between feeding their kids or going in for necessary treatment, treatment that sometimes dictates whether they will live to see their children grow up.

This is about adults being treated early in a preventative manner because they can afford to do so, rather than waiting and being faced with exorbitant emergency room or in-patient charges because they had to put off their care.

Of course, we counsel sensible debate about the financial needs and priorities of society, no question. But what we’ve done with the Medicaid issue is create an awkward and uncomfortable situation that fits in seniors (Medicare), most families (Obamacare and its subsidies) and many kids (those eligible for the Children’s Health Insurance Plan, or CHIP), but leaves out a major chunk of those at the lowest end of the income chain, even if they’re actively working or seeking work.

That makes no sense.