by .....exempt .....that does not mean the states do not have to follow the Affordable Care Act (Obamacare law.) it just means that each state can apply for special permission so that they do not have to expand their medicaid/medicare program to accept more people on medicaid and medicare if they dont want to. in those states that have received their exemptions just means they dont have to lower their income brackets for medicaid//medicare and increase their number of how many people they will accept on medicaid\medicare.

regardless of whether a state gets their exemption from expanding their medicaid/medicare program to meet the Obamacare standards all americans must now have basic mental and physical health insurance. in the states that have exemptions from expanding their medicaid/medicare programs those americans must get other insurance plans if they dont meet the existing medicaaid medicare standards, unless they meet other individual case by case exemptions. example if you are homeless are exempt from having to get \purchase healthcare insurance according to the law.