Think Progress came up with an excellent catch late yesterday. They obtained a letter from Texas Governor Rick Perry’s Administration, which projects the state health care budget by assuming the expansion of Medicaid to everyone below 133% of the poverty line by 2014:

Greta Rymal, Deputy Executive Commissioner for Financial Services, has projected the fiscal impact of this rule for three years, assuming that all clients will be eligible for Medicaid following the expansion of the Medicaid program in January 2014 [...]

Perry has been among the most vocal GOP governors in saying that his state would not accept the Medicaid expansion. But here, in an official document, it assumes expansion. The reason for this letter in the first place is due to Texas trying to de-fund Planned Parenthood:

Several months ago, the Texas health commissioner signed a rule to ban Planned Parenthood or any organization the state considers an “abortion affiliate” from participating in Medicaid’s Women’s Health Program, which “provides low-income women with family planning exams, related health screenings and birth control” throughout Texas. The state’s discrimination against a specific health provider violated federal rules and led Washington, which had financed 90 percent of the WHP through Medicaid funds, to block Texas from receiving further funding for the program.

Basically, 52,000 women would be out of luck in the Women’s Health Program under this rule. If Perry creates a fully state-funded alternative, he can deny Planned Parenthood funding. But without the expansion, that would be expensive. So the assumption that everyone gets covered through the expansion lessens the impact.

This doesn’t mean that Texas will accept the expansion, of course. It’s only a document that uses some sleight-of-hand to make the uninsured vanish. But it shows how untenable it is for a state to let their poor waste away. Robin Marty has more.

Of course, this also brings up the point that just having Medicaid doesn’t mean you can find a doctor.

Sandra Decker, an economist with the Center for Disease Controls, recently poured over the 2011 National Ambulatory Medical Care Survey, which asks doctors whether they would accept new Medicaid patients.

What she found could spell trouble for the health care law: More than three in ten doctors – 31 percent – said no, they would not.

Obviously, if more Americans are covered under Medicaid, that means a larger segment of patients that doctors would have to deny. But it brings up the important point that insurance does not equal care. In states that don’t reimburse heavily under Medicaid, doctors find it more sensible to deny those patients. The Affordable Care Act does try to deal with this by increasing Medicaid reimbursement rates for primary care doctors. But that only lasts through 2014, and under this schedule, would end precisely during the coverage expansion. And it’s limited to just primary care physicians.

The more you untangle the Medicaid portion of the law, the more problems exist.