Jeffrey Young of HuffPost has a good primer on the potential impact on hospitals of any state refusals to implement the Affordable Care Act’s Medicaid expansion mandate, and of preliminary plans by hospitals to pressure Republican lawmakers to stand down on their threats of obstruction. While Young provides data on Florida and Arizona as well, it’s the Texas numbers that are stunning:

Getting the Medicaid expansion in place has already become the “number one priority” for the Texas Hospital Association, said John Hawkins, the senior vice president for advocacy and public policy at the organization. “It’s the kind of thing that hits our members right on the margin when they’re trying to digest other payment cuts,” he said.

Twenty-seven percent of working-age Texans, or more than 6.1 million people, were uninsured in 2010, according to the Kaiser Family Foundation. That’s the highest rate in the nation and the second-highest number to California’s 7 million people. Under the Medicaid expansion, 2.5 million Texans would qualify, the Urban Institute estimates.

But Texas Gov. Rick Perry (R) has been a staunch opponent of health care reform and his administration has indicated a willingness to opt out of the Medicaid expansion. For Texas hospitals, which absorbed $4.6 billion in unpaid bills and charity care in 2010, that’s a problem, Hawkins said.

I should think so. Presumably hospitals and their associations in all the estimated fifteen states where Republican governors and/or legislators are already rattling sabers against the Medicaid expansion are making plans not only to lobby, but to inform the public of how the costs of uncompensated emergency care are shared with everyone else. The fiscal realities of the Medicaid expansion, with its extraordinarily high “super-match” of federal funds (beginning at 100% and dropping gradually to 90%), will also be thoroughly aired in response to vague alarms from conservatives that the expansion will overwhelm state budgets.

This won’t matter much to the Tea Folk who will use their own leverage to oppose the expansion, and whose response to the quandary of hospitals might well be a blithe suggestion that Congress repeal the federal law requiring emergency care for everyone (let ’em be more responsible!), even though it was signed by none other than Ronald Reagan. The debate won’t be between two different accounts of the policy implications and fiscal consequences of accepting or rejecting the Medicaid expansion, but between care-givers and ideologues speaking very different languages.

Ed Kilgore

Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.