I keep seeing these confident predictions from health care experts that no state would be so foolish as to reject the Medicaid expansion for their state. I want to set up a poker game with these people, to provide for my family in retirement. How many times can you say “well that’s so radical and extreme, it could never happen!” and be wrong before you review your assumptions? Here comes the New York Times with the first wave of quotes from Republican states. I’m going to annotate these with the number of people who would be covered under the Medicaid expansion (a full list will come later in the post):

Republican officials in more than a half-dozen states said they opposed expanding Medicaid or had serious doubts about it, even though the federal government would pick up all the costs in the first few years and at least 90 percent of the expenses after that [...]

Gov. Dave Heineman of Nebraska (83,898 covered in Medicaid expansion), a Republican who is chairman of the National Governors Association, indicated that he was against expanding Medicaid eligibility.

“As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased,” Mr. Heineman said.

In South Carolina (344,109 covered), Rob Godfrey, a spokesman for Gov. Nikki R. Haley, said, “We’re not going to shove more South Carolinians into a broken system that further ties our hands when we know the best way to find South Carolina solutions for South Carolina health problems is through the flexibility that block grants provide.”

In New Hampshire (55,918 covered), State Representative Andrew J. Manuse said he and other Republicans were already working to block the expansion of Medicaid. “We can’t afford it,” Mr. Manuse said. “It’s as simple as that. Thank God the Supreme Court gave us an option.”

The idea that you can just point to a set of numbers and say “but it’s almost all paid for by the federal government!” and convince ideologically motivated conservatives with that reasoning is really rich. The consensus opinion on the right is that giving free services to poor people puts them on the road to serfdom and crushes their innovative spirits and shackles them rather than allowing them to grow and succeed. Really they don’t want rich people to pay for “others” to get free stuff. Either way, that’s the prevailing opinion in red states in a time that’s as conservative as its been in the last century.

And Republicans will point to the fact that expanding their rolls will bring attention to the Medicaid program, leading to people currently eligible to sign up, raising costs for the states not covered by the federal government. Ohio’s John Kasich is already making this argument, claiming it will cost the state $940 million in the first two years of implementation. Considering that practically all states are in the midst of budget crunches, with Medicaid being one of the two major state budget line items (along with public education), this argument will be effective.

The bizarre outcome for low-income residents in poverty in states that refuse the Medicaid expansion is that they will not be taxes for failing to purchase health insurance under the hardship exemption, but they will also not be eligible for subsidies on the exchanges, because the law assumed they would be captured by Medicaid. So they would be frozen in amber in a cruel, pre-ACA health care system, where their only recourse is the emergency room or free clinics like Remote Area Medical. Given that, it’s good news that the American Hospital Association plans to put up a fight:

Richard J. Umbdenstock, the president of the American Hospital Association, said that hospitals around the country would lobby for the Medicaid expansion. “If states do not avail themselves of this opportunity,” he said, “the federal money will go to other states, and hospitals will be left with large numbers of the uninsured.”

But if logic ruled this debate, and governors could be counted on to look at the costs of Medicaid expansion versus the costs of uncompensated care and make their determination thusly, we wouldn’t have a problem.

Pro Publica and Yahoo have put together state-by-state looks at how many people would be covered under the Medicaid expansion, based on this data from the Kaiser Family Foundation (also supplemented by this data from the Centers on Medicare and Medicaid Services).

This chart at Pro Publica highlights the 28 states that sued to overturn the ACA (26 in the NFIB lawsuit, and 2 in the independent lawsuit of Virginia and Oklahoma), and what their Medicaid expansion would look like. I’ll put the breakdown on the flip, but adding them all up, you’re talking about 9.15 million low-income Americans at risk from the opt-out of the expansion. I don’t expect all 28 states to opt out (Washington state won’t, for example), but it’s the benchmark we have at this time.

To be clear, I think this is a terrible outcome. CMS showed in their study that Medicaid enrollment correlates with more regular primary care, higher utilization of preventive care, and “significantly better self-reported health.” The Medicaid expansion was one of the jewels of the ACA. By giving states more leverage to reject it, the Supreme Court badly damaged the law, contrary to the reports spinning this as an unalloyed victory.

Here are those state-by-state expansion numbers, on the flip:

States who sued to overturn the ACA and their Medicaid expansion estimates (per Kaiser Family Foundation)

VA: 245,840
OK: 357,150

ME: 43,468
PA: 482,366
OH: 667,376
IN: 297,737
MI: 589,965
WI: 205,987
IA: 114,691
SC: 344,109
GA: 646,557
AL: 351,567
FL: 951,622
MS: 320,748
LA: 366,318
TX: 1,798,314
KS: 143,445
NE: 83,898
SD: 31,317
ND: 28,864
WY: 29,899
CO: 245,730
AZ: 105,428
UT: 138,918
ID: 85,883
NV: 136,563
WA: 295,662
AK: 42,794