When the Supreme Court removed the barriers to states opting out of the Medicaid expansion of the Affordable Care Act, one of the first states to say they would reject the extension of additional coverage was Texas. This would have an outsized effect on the reach of the expansion, since moving up the eligibility of Medicaid to 133% of the poverty level would cover an additional 1.8 million residents of the Lone Star State.

But Texas may not have the last word on that. Several counties in the state may band together to offer the expansion to their constituents. This looks a little more like shifting costs onto the federal government than expanding the rolls of covered citizens, however, because these counties have a number of existing programs in place.

For years, Texas’s six most populous counties, as well as some smaller localities, have offered free or low-cost health care for uninsured residents with incomes as much as three times the federal poverty level, or about $57,000 for a family of three. The cost of the programs: about $2 billion a year.

If some of the patients were enrolled in Medicaid, the state-federal health-care program for the poor, it could be salve for cash-strapped county budgets and a boon for local taxpayers.

George Hernandez Jr., CEO of University Health System in San Antonio, came up with the idea of the alternative, county-run Medicaid expansion, and said he has been discussing it with other officials in his county, Bexar. “They are all willing,” he said. He added that he has also been talking up the proposal with officials in other big counties, such as those including Houston and Dallas, and is optimistic they’ll support the idea.

This may work out better for residents. I don’t know much about the low-cost health care program in these Texas counties, but bumping up to Medicaid may be a more stable option. Apparently the services are fixed to a particular hospital district, so certainly Medicaid would be more flexible for residents. The article says this would lower out-of-pocket costs for the individual patients, too. Plus, it would certainly aid local government budgets, and given the dynamic of local austerity, it may be good on its face to transfer funds up to the federal government, as a back-door stimulus program.

However, there are roadblocks. The Texas legislature and the White House would have to support this program. Right now there’s a requirement that all counties have the same standards for Medicaid eligibility in a given state. That would have to get waived. I would think that this would have a lot of trouble getting through the state legislature, which is dominated by members outside the big counties. But perhaps it could be argued on the grounds that this would bring money back into the state.

The more counties that join into the program, the more of a chance at success. Over half of Texas lives in one of the hospital districts that offer coverage of this type. However, when the federal government starts to cover only 90% of the Medicaid expansion over time, the counties would have to come up with that revenue. It’s less than they provide now for low-income health care, so maybe this wouldn’t be a hurdle.

Certainly, this presents a novel way to get around Rick Perry. But if the ideologically inclined Texas legislature has anything to say about it, I’m not sure this will become a reality.