West Virginia Gov. Earl Ray Tomblin (D) announced in a press conference on Thursday that his state would take part in Obamacare’s optional Medicaid expansion, calling the decision “the best choice for West Virginia.” But many states still remain up in the air with their decisions, either because they haven’t decided yet or because state executives and legislators are at odds with each other on the issue — and time is running out.

Speaking at St. Francis hospital and flanked by nurses, doctors, and hospital administrators, Tomblin laid out the medical and financial case for expanding Medicaid eligibility — a conclusion that he reached after commissioning a study to examine such a move’s effects on West Virginia. “Expansion will allow us to provide insurance coverage to 91,500 West Virginians,” said Tomblin.

Indeed, West Virginia has much to gain and very little to lose by embracing the Obamacare provision. The state has abysmal health demographics, and over half of West Virginia’s uninsured population lives below 138 percent of the Federal Poverty Level (FPL). These poor and vulnerable populations would gain access to health coverage under the Medicaid expansion, leading the Kaiser Family Foundation to conclude that expansion will reduce the number of uninsured West Virginians by a staggering 67 percent.

Those numbers likely led Tomblin to his decision. But the moderate Democrat has an advantage that governors of other conservative — and highly uninsured — states don’t: the almost assured support of his legislature. Democrats hold a supermajority in the state Senate and an eight seat edge in the House of Delegates, and both of West Virginia’s U.S. senators also support expanding Medicaid, making intraparty barriers unlikely.

The same cannot be said of Republican Govs. Jan Brewer (AZ) and Rick Scott (FL), who have been lobbying for Medicaid expansion after intense pressure from hospital associations and advocates for the poor. Their Republican-controlled state legislatures have been bending over backwards to stop it from happening. Although there is no hard deadline for expanding Medicaid under Obamacare, many of these states’ legislative sessions are quickly coming to an end — meaning that if no agreement is reached soon, they won’t receive the additional federal funds and won’t be able to extend coverage to low-income residents for at least the first full year of Obamacare implementation.

Texas and Louisiana face similar issues. Although some GOP lawmakers in those states are contemplating Arkansas Gov. Mike Beebe’s (D) alternative “private option” — which would take federal money and use it to help an expanded Medicaid pool buy private insurance — those efforts also remain in limbo, as former and current Republican presidential aspirants Govs. Rick Perry (TX) and Bobby Jindal (LA) have oscillated between flat-out rejecting expansion and being coy about their intentions.

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Last Friday, the U.S. Department of Health and Human Services (HHS) announced that it would allow states to pursue waivers letting them privatize their Medicaid expansions under Obamacare — an idea that took root with a deal worked out by Arkansas Gov. Mike Beebe (D) and the Obama HHS last month. Commentators and policy-makers heralded it as a “game-changer” for the reform law, as it could influence red states — many of which have high poverty levels and massive uninsurance rates — to extend coverage to poor people and help facilitate a major Obamacare provision.

But as Medicaid policy expert and George Washington University professor Sarah Rosenbaum smartly pointed out to the Washington Post’s Sarah Kliff in March, using federal dollars to put Medicaid-eligible populations into privately-contracted plans isn’t a novel concept at all — to the contrary, states have actually been doing it for decades through their increasing use of Medicaid managed care (MMC) arrangements. These arrangements contract beneficiaries’ care out to private insurers and providers, and a full “two-thirds of Medicaid enrollees now receive most or all of their benefits in managed care.”

Republicans have historically been strong proponents of MMC, touting its potential to cut costs while protecting poor Americans’ benefits. But with HHS’s new offer to institute a wide-scale version of this program now on the table, several notable Republicans are balking at the idea — including some who have pushed for similar measures themselves in the recent past:

1. TEXAS GOV. RICK PERRY. The 2012 presidential aspirant has been on an anti-Medicaid bender of sorts lately, declaring that “Texas will not be held hostage by the Obama administration’s attempt to force us into the fool’s errand of adding more than a million Texans to a broken system.” Yet, during his presidential run in late 2011, Perry struck a massive deal with federal officials allowing him to move close to a million Medicaid beneficiaries into managed care. Perry heralded the move in a press release, saying, “By approving Texas’ Healthcare Transformation and Quality Improvement Program Waiver, state and local officials can provide more efficient and effective care, and implement locally-tailored health solutions.” Apparently, Perry doesn’t view the Obama Administration’s offer on privatized Medicaid to be a similar opportunity for implementing “locally-tailored” solutions.

2. LOUISIANA GOV. BOBBY JINDAL. One of Obamacare’s most ardent critics, Jindal has steadfastly refused to expand Medicaid in his low-income state, saying that “Medicaid still operates under a 1960s model of medicine with inflexible, one-size-fits-all benefits and little consumer engagement and responsibility.” So far, he has stuck by that decision despite the urging of local lawmakers and his own state’s hospital chains. But back in 2011, Jindal aggressively — and successfully — pushed through an expansion of Louisiana’s MMC program, shifting 900,000 Medicaid and CHIP beneficiaries onto private, managed care. The measure was actually Jindal’s number one health care-related priority for 2012, and his administration publicly sold it “as a way to save taxpayer money and provide better care through coordination among doctors, hospitals and other medical professionals.”

3. MISSISSIPPI GOV. PHIL BRYANT. In an interview with Kaiser Health News, the Mississippi governor said, “I would rather pay extra to Blue Cross [to help cover uncompensated costs for the uninsured], rather than have to raise taxes to pay for additional Medicaid recipients” — a tacit endorsement of a managed care scheme. In fact, in 2012, Bryant signed a bill allowing Mississippi’s Medicaid division to increase the proportion of beneficiaries who could be placed onto managed care programs from 15 percent to 45 percent of the aggregate pool. Bryant has attributed his opposition to Medicaid expansion to his view that the program disincentivizes people “to find a better job, or to go back to school, or to get [into] a workforce training program.”

Two former Louisiana state Department of Health and Hospitals (DHH) secretaries have a message for Gov. Bobby Jindal (R): accept federal funding for taking part in Obamacare’s Medicaid expansion, or see taxpayer money go to funding other states’ expansions while low-income Louisianans suffer.

Fred Cerise and David Hood, the latter of whom is a Republican who actually succeeded Jindal — a former DHH head himself — after Jindal left to become president of the University of Louisiana public schools system in 1998, urged the governor to join the growing ranks of Republican state officials who have embraced Medicaid expansion in a Baton Rouge Advocate newspaper ad. The advertisement states, “Medicaid expansion offers a path to regular access to health care for working adults.”

The ad goes on to note that forgoing the expansion won’t just deprive low-income Louisiana residents of crucial health coverage, but is fiscally irresponsible, too: “If Louisiana refuses to participate, our share of the money that pays for this program will be used to support the Medicaid expansion in other states and our low-income residents will continue to lack access to care.” Multiple studies, including a comprehensive Kaiser Family Foundation analysis, have shown that states expanding Medicaid will receive massive federal funding for very little state input.

Jindal has a decidedly poor record when it comes to safety net health care entitlements, instituting massive cuts to state programs that assist vulnerable groups such as poor first-time moms and low-income HIV patients. Jindal has also been a staunch Obamacare critic and has so far explicitly ruled out expanding Medicaid — however, there have been recent reports that he and other skeptical GOP state leaders might be open to a modified expansion along the lines of the unique deal struck between Arkansas Gov. Mike Beebe (D) and the Obama Administration.

Advocates for the poor and hospital associations have been pressing Republican leaders to accept unusually generous federal funding to expand Medicaid, warning officials that providers might buckle under the weight of uncompensated care costs without a larger pool of insured low-income Americans who can actually afford to pay their medical bills. Expanding Medicaid faces an uphill battle even in states where GOP governors have embraced it, as they must still convince skeptical lawmakers in their own party to go along with the plan.

A top Republican is suggesting that President Obama delay health care services to millions of middle and lower-income Americans to offset the automatic across-the-board budget cuts that will go into effect on March 1 if Congress does not reach a spending deal.

Appearing on Meet The Press on Sunday, Louisiana Gov. Bobby Jindal (R-LA) advised Obama to put off implementing the Affordable Care Act’s health care exchanges that are due to go online in 2014 and the expansion of the Medicaid program to offset the looming sequester cuts:

JINDAL: Just delay the Medicaid expansion, delay the health care exchanges so they can work with states on waivers, on flexibility. You can save tens of thousands of dollars there and you’re not even cutting a program that’s started yet — just delaying.

Delaying implementation of these key coverage expansion provisions would throw the law into chaos and deny health services to millions of Americans, many of whom are at or just above the federal poverty line and are struggling with medical bills. 771,600 adults and 124,200 children currently go without health care coverage in Jindal’s home state of Louisiana, for instance. The governor has declined to move forward with a state-run exchange for consumers to buy insurance, leaving its operation to the Department of Health and Human Services, and opted out of the Medicaid expansion under the law.

Defunding the Affordable Care Act has become a popular sequester offset on the right. Last week, Sen. Lindsey Graham (R-SC) said the government should protect the Defense Department from automatic spending cuts by slashing $1.2 trillion from the law. “Well, all I can say is the Commander-in-Chief thought — came up with the idea of sequestration, destroying the military and putting a lot of good programs at risk. It is my belief — take Obamacare and put it on the table,” Graham said.