Georgia will soon wrestle with two very important choices on Medicaid –- choices that will shape the future health care landscape of the state.

The first concerns the restructuring of the government program, which covers, along with PeachCare, 1.7 million Georgians.

As part of a ‘‘redesign’’ effort, the state has been studying the idea of bringing managed care to Medicaid members in nursing homes and to people with disabilities.

But this week’s Supreme Court ruling on the health reform law may help sidetrack any major design change, due to the gravity of the second choice: whether to expand Medicaid.

The court, in a ruling that was otherwise favorable to the health care law, threw out a key federal enforcement provision for Medicaid. That means states now have the option not to increase their Medicaid rolls.

“We’re in a very uncertain time,’’ said the commissioner of the Georgia Department of Community Health, David Cook, who discussed the ramifications of the court’s surprising Medicaid ruling with GHN on Friday.

The ruling sets up “the beginning of a national debate about Medicaid,’’ he said.

And that Medicaid expansion decision for Georgia will set up a titanic battle between many hospitals, doctors and health providers, joined by Democrats and consumer advocates, against “Obamacare’’ opponents and people who worry about the cost to the state, or fear the government program’s continued growth.

At stake will be billions of federal dollars that would go along with a decision to expand, along with coverage for hundreds of thousands of poor Georgians. Also at stake will be, if Georgia expands Medicaid, a cost of billions of state dollars over 10 years, state officials calculate.

Medicaid is jointly financed by the state and federal governments, with the latter picking up roughly two-thirds of the cost in Georgia. But the feds would pay 100 percent of the expansion over the first three years.

One unanticipated situation created by the court decision is that the poorest adults in a state would not get Medicaid coverage if a state rejects expansion. They would also not be able to obtain subsidies that would defray the costs of getting coverage through a health insurance exchange.

“It’s a huge chunk of the uninsured in Georgia,’’ said Cindy Zeldin, of the consumer group Georgians for a Healthy Future.

Already, Republican governors in Kansas, Nebraska and South Carolina, among other states, say they would have trouble affording the relatively small share of costs that states would eventually have to pay for the Medicaid expansion, the New York Times reported Saturday.

A spokesman for South Carolina Gov. Nikki Haley told the Times, “We’re not going to shove more South Carolinians into a broken system that further ties our hands.’’

Gov. Nathan Deal, also a Republican, remained noncommittal Thursday about expansion in Georgia.

Four Democratic congressman from Georgia –- Reps. John Lewis, David Scott, Sanford Bishop and Hank Johnson -– wrote a letter to Deal on Friday urging him to expand Medicaid as ‘‘the right thing to do and a good deal for Georgia.’’

“In Georgia, working people are currently eligible for Medicaid only if their incomes do not exceed 50 percent of the federal poverty level (or about $9,500 for a family of three), while adults without dependent children are not currently eligible at any income level,’’ the letter said. “As a result, 55 percent of adults below poverty are uninsured in Georgia. . . . This is unacceptable, and leads to poor health outcomes and increased costs as these Georgians seek care at the emergency room for untreated illness. ‘’

Not expanding would hurt the safety-net hospitals that serve the uninsured poor, Kaiser Health News noted. Not only would the hospitals miss out on the expansion of Medicaid coverage, but over time the health act reduces the Medicare and Medicaid surpluses they collect for handling a disproportionate share of low-income patients.

“If a state chose not to participate in the expansion, the poorest of the poor would be impacted,” John Haupert, CEO of Grady Health System, told KHN.

If Georgia opts out of the Medicaid expansion and Congress doesn’t change the rules, the hospital will be forced to turn for more funding to the counties it serves, he said to KHN, “and they are not in a position to make up that difference right now.”

Meanwhile, Cook, the head of the state’s Medicaid agency, said the court’s ruling could lead to ‘‘whole new approach on Medicaid.’’

“It’s interesting that Georgia and the states have been calling for more flexibility’’ on Medicaid, he told GHN. “The court agreed the states needed more flexibility.’’

Cook said that the program could go to a block grant, where a state would get a defined amount of money from the federal government to run its program as it wants.

Deal has said he supports that idea.

Cook said he doesn’t see the ruling affecting the timetable for the redesign decision, which the state still expects to make sometime this summer.

“One of the options on the table is to not do something, and wait for the dust to settle,’’ he said.

That’s an outcome that some in the health care industry already think is likely for the redesign: Keeping things basically the way they are, with a few tweaks.

Cook said that after the state makes its decision on the issue, the agency will continue to work with the task forces of stakeholders that have provided input to the redesign process.

But most health care experts turned this week to the expansion as the much bigger issue. As it stands now, vastly different health care systems could arise in different states –- depending on whether or not they accept the Medicaid expansion.

Zeldin said about half of Georgia’s uninsured stand to gain coverage through an expansion.

“Billions of dollars will flow directly to doctors and hospitals so that they can provide necessary medical care, and this infusion of resources into Georgia will spark growth in the health care sector and, in turn, the state’s economy,’’ she added.