As Congress debates comprehensive immigration reform, members of both parties have insisted on barring undocumented immigrants who achieve provisional legal status from receiving Medicaid coverage or Obamacare subsidies (a provision that was already part of the health law). But preventing these immigrants from gaining basic health benefits is actually a fiscally irresponsible model that will only raise health care spending and contribute to a sicker U.S. population.

The common argument against providing health care to undocumented immigrants is that, since they’ve broken the law, they should be punished. A part of that punishment involves denying them health care services through public entitlement programs or federal subsidies that are dependent on Americans’ tax dollars. “We must value the contribution of immigrants to our country. In doing so, we must protect our borders, we must protect our workers, and we must protect the taxpayer,” said House Minority Leader Nancy Pelosi (D-CA) on Thursday.

But the taxpayer already foots the bill for undocumented immigrants’ care — just in an incredibly inefficient and half-baked way. Under the auspices of the Reagan-era Emergency Medical Treatment and Active Labor Act (EMTALA), hospital emergency rooms can’t turn away patients based on their citizenship or insurance status. That doesn’t mean that their care magically becomes free — undocumented men and women who use the emergency room are still slapped with a hefty hospital bill.

However, if they are unable to pay that bill — which is fairly likely considering that they probably don’t have any insurance — then a combination of the federal government, state governments, hospitals, and other American consumers of U.S. health care are forced to absorb the cost. In turn, that raises prices for medical services, since hospitals want to recoup some of their losses. Some studies have estimated the price of subsidizing undocumented immigrants’ health care at about $10.7 billion per year.

The federal government has long been aware of this problem. In fact, soon after EMTALA’s passage, lawmakers authorized a special Medicaid fund that mostly goes towards subsidizing emergency treatments for undocumented immigrants. The program costs about $2 billion per year, and most of that money is used on delivering babies for pregnant, undocumented women who go to the emergency room.

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Gov. Jan Brewer (R-AZ) has a message for her party: expand Medicaid — or else.

The combative GOP governor is sticking by a threat she made to veto all legislation until lawmakers resolve the 2014 state budget and pass Obamacare’s Medicaid expansion. On Thursday, Brewer proved that wasn’t just talk, vetoing five bills sent to her desk in quick succession.

“I warned that I would not sign additional measures into law until we see resolution of the two most pressing issues facing us: adoption of a fiscal 2014 state budget and plan for Medicaid,” wrote Brewer in her veto message. “It is disappointing I must demonstrate the moratorium was not an idle threat.”

Arizona officials only have five weeks before reaching the constitutional deadline for passing a budget. Last Thursday, six Republican state senators joined a unified Democratic caucus to pass a Medicaid expansion bill — but efforts have been gummed up in the state House since then.

Brewer isn’t letting the issue slide. She has been touring the Grand Canyon State to shore up support for the expansion and put pressure on reticent lawmakers in her own party.

Some Republicans opposed to the expansion have warned of dire political consequences for lawmakers who buck the traditional conservative opposition to Medicaid. In a letter to Republican legislators, the chairman of the Maricopa County Republican Committee wrote of the state senators who voted for expansion, “Their egregious actions will have serious consequences. Their political careers are all but over and their days numbered.” He referred to Brewer as a “rogue governor” in the same statement.

But Brewer appears to be sticking by her convictions. At the beginning of the year, she became the third Republican governor to embrace expansion, asserting that it would provide health coverage to 50,000 low-income Arizonans. While promoting the expansion in March, Brewer attested to the dire consequences of failing to expand Medicaid. “The human cost of this tragedy can’t be calculated,” said Brewer, flanked by public health officials, doctors, and advocates for the poor. “Remember, there is no Plan B.”

The Kaiser Family Foundation (KFF) estimates that expanding Medicaid would cut Arizona’s uninsurance rate by nearly a third.

The debate over Medicaid expansion has devolved into a GOP platform for grandstanding about the health reform law and the Obama administration. But an NPR article from Tuesday shines a light on what, exactly, most Republican governors’ refusal to expand Medicaid will mean for real Americans by examining poor communities in a state headed by one of Obamacare’s most ardent critics: Gov. Rick Perry (R-TX).

The piece centers on particularly destitute populations in southern Texas, where some uninsured residents are so poor, sick, and unable to cope with their medical bills that they resort to desperate measures such as crossing the border into Mexico for medications and even sharing their insulin shots:

[M]any of those who live here [in Brownsville] — including poor Latino immigrants, both legal and undocumented — suffer from diabetes and lack of insurance. Some of those uninsured diabetics, including American citizens and others living here legally, used to go across the border to Matamoros, Mexico for insulin. But now with the fear of brutal drug violence and tougher border restrictions, families share their insulin shots rather than risking the crossings.

A community health worker in Brownsville noted that “many of those who used to cross the border would qualify for Medicaid under the expansion offered by the health care law.”

This inequity is further exacerbated when dealing with a more serious or life-threatening chronic condition. One official at Brownsville’s local health clinic described how difficult it is to provide specialty care services to the poor and uninsured, emphasizing that Medicaid coverage would make it far easier to convince physicians to take on patients:

“Once you diagnose a cancer, then what?” said Dr. Henry Imperial, the clinic’s medical director. “How are you going to give me chemotherapy or surgery or radiation therapy? It goes out of our hands.”

Those complications can make for some intense arm-twisting among Brownsville’s medical ranks. Imperial said he often plies fellow doctors in town with beer to see his uninsured patients. “When they see me approaching them, they start running away,” he joked before turning somber. “It’s just tough. I could not do an appendectomy. I cannot operate on gall bladders. I need a surgeon.”

Most specialists, including surgeons, in Brownsville, accept Medicaid, said Imperial. “It does pay for services that otherwise the patient does not receive.”

GOP leaders like Perry and even some of the more serious conservative academic critics of Obamacare’s Medicaid expansion regularly cite the program’s low reimbursement rates as a reason for dismissing it. Perry has denounced expansion as doubling down on a “broken system,” since doctors won’t want anything to do with Medicaid to begin with.

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Over 60 percent of the Americans living in the Deep South support Obamacare’s Medicaid expansion, according to the results from a new poll that surveyed a broad sample of people in Alabama, Georgia, Louisiana, Mississippi, and South Carolina.

The poll, conducted between March and April by the Joint Center for Political and Economic Studies, found that support for Medicaid expansion is somewhat divided along partisan lines. Nevertheless, a solid majority of residents in each of the five Deep South states favor expanding the public insurance program to extend coverage to additional uninsured Americans:

That public support stands in sharp contrast to the five states’ political leaders, who have resisted cooperating with health care reform at any cost. The GOP governors in each of those Southern states — Govs. Robert Bentley (R-AL), Nathan Deal (R-GA), Bobby Jindal (R-LA), Phil Bryant (R-MS), and Nikki Haley (R-SC) — have refused to expand their Medicaid programs.

“This survey clearly shows that governors and state legislators in the South who are resisting the Medicaid expansion are out-of-step with their constituents,” Brian D. Smedley, the director of the Joint Center’s Health Policy Institute, pointed out.

The broad public support for Medicaid expansion in this region makes sense. Low-income Americans in the South who don’t currently qualify for their state’s Medicaid program are being forced to simply skip out on medical care, and expanding Medicaid’s eligibility levels would ensure that they can access the health treatment they need. Deeply red Southern states also tend to have worse health outcomes compared to Democratic-controlled states on the coasts, and expanding Medicaid could help lessen some of those disparities.

But political resistance to Obamacare, even in the states that stand to benefit the most from it, remains strong. The governors in highly uninsured states are still refusing to consider cooperating with the Medicaid provision of the health reform law. And even when Republican governors reluctantly agree that Medicaid expansion is the right decision for their constituents, GOP-controlled legislatures in their states continue to block it.

As the political fight over Obamacare continues, Republican legislators in highly uninsured states have turned their back on Medicaid expansion — despite the fact that expanding the public insurance program could extend coverage to millions of their constituents. Of course, even if stringently anti-Obamacare politicians refuse to cooperate with health reform, the law will still take effect. But that doesn’t necessarily mean those red states won’t feel the impact of refusing to add more residents to their Medicaid rolls.

Health care outcomes already vary widely across states. Unfortunately, health policy does too. The states that are already among the nation’s healthiest are the ones taking steps to ensure their low-income residents will have the insurance coverage they need — while the unhealthier, more highly uninsured GOP-led states are refusing to do the same. As an analysis from the Los Angeles Times points out, the health care reform law can’t change the fact that the stubborn lawmakers resisting Medicaid expansion are likely going to deepen the health disparities that already exist across the country:

With nearly every GOP-leaning state on track to reject an expansion of the government health plan for the poor, the healthcare law’s goal of guaranteed insurance will become a reality next year mostly in traditionally liberal and moderate states. These states already have higher rates of health coverage.

Residents of these states — concentrated in the Northeast, upper Midwest and West Coast — also have better access to doctors and are less likely to die from preventable illnesses.

Colon cancer deaths in states opposing Medicaid expansion, for example, are an average of 16% higher than in pro-expansion states, according to a Los Angeles Times analysis of state health data.

Deaths from breast cancer are 8% higher on average in anti-expansion states. And adults under 65 are 40% more likely on average to have lost six or more teeth from decay, infection or gum disease.

An earlier analysis found that the governors for the most unsinsured cities in the United States have been resistant to expanding Medicaid. And even after some of those governors started to come around — most notably, Florida’s Rick Scott — the Republicans in the state legislature have continued to block the initiative. Opposition persists despite the fact that the poor Americans in the South, who are already being forced to delay their medical care because they can’t afford it, stand to gain the most from Medicaid expansion.

This isn’t the only example of health disparities becoming sharply divided by region. Abortion access, another area of health policy that’s largely been left up to states’ interpretation, also varies widely from California to Mississippi to North Dakota to New York. “It shouldn’t be that simply because you live in Mississippi that you don’t have the same health care that you can get if you lived in California,” one abortion doctor who travels to practice at Mississippi’s last remaining abortion clinic recently pointed out. Nonetheless, that’s the growing reality for the entire health care sector.

Over ten percent of all doctors and nurses on the government’s Medicare and Medicaid blacklist end up on it because they defaulted on government-backed student loans. Medical workers on the blacklist are barred from treating Medicare and Medicaid patients or receiving federal reimbursements for a predesignated time period.

According to a Modern Healthcare analysis of federal records, more than 5,400 of the 51,729 people on the government health entitlement blacklist were placed on it after failing to pay an HHS-backed medical student loan. Given a still-shaky economy, some in the health care sector expect that trend to continue:

[Government data] show that one of the most common reasons for getting barred is failure to repay HHS-backed student loans: 5,417 people are currently kicked out of Medicare for that.

The number of annual exclusions related to student loans has grown steadily in the past decade, peaking at 517 in 2011 before declining again. “That is tied to the economy, and I would expect that to continue to rise,” [said Lynn Gordon, a Chicago-area hospital group partner].

The increasing frequency of default-related blacklisting could prove problematic as the Obama Administration tries to entice more medical students to become primary care and family doctors. Primary care providers and nurse practitioners will be crucial to effective Obamacare implementation, since the health law is expected to drive up demand for medical services as millions of previously uninsured Americans gain coverage.

But the ballooning cost of a medical education could end up being a major barrier to the Administration’s recruitment efforts. According to the Association of American Medical Colleges’ (AAMC) 2012 report on medical school debt, “86 percent of medical school graduates had education debt, with a median amount of $162,000″ in 2011 — a number that has been rising steadily over the years:

AAMC estimates that a borrower with the median $162,000 debt “would have monthly payments ranging from $1,500 to $2,100 after residency.”

That disproportionately affects the very primary care doctors that are integral to health care reform and the U.S. medical system at large. In a 2012 report, consulting firm Merritt Hawkins & Associates found that family practitioners, pediatricians, and psychiatrists are the lowest-paid physician groups in the U.S. with a base pay of $189,000.

While that’s still a lavish salary compared to average U.S. compensation, it pales in comparison to specialist pay — and as the entitlement blacklist numbers underscore, that contributes to a system in which care providers are banned from treating certain patients for purely financial, rather than medical or criminal, reasons.

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Faith leaders were an important group pushing red state leaders to accept Obamacare’s Medicaid expansion. And with open enrollment for Medicaid and the law’s insurance marketplaces inching closer, they’ll be crucial to making sure that Americans know how, where, and when to sign up.

To that end, Maryland officials are currently holding a summit with over 150 faith leaders in which they explain the nuances of the law — and urge religious leaders to distribute that information by educating their congregants and communities. Faith leaders are enthusiastic about the plan, since their day-to-day dealings with their communities gives them a unique perspective on Americans’ needs and struggles:

The Rev. Janet Craswell, of the Salem United Methodist Church in Brookeville, described the summit as very helpful. Although her church is in a small Maryland community, Craswell said she has been hearing from a wide variety of people who will be impacted by the overhaul, including families with unemployed and uninsured young adults, people with disabilities and small business owners who are confused and concerned about how the law will impact their businesses.

“We see people every day,” Craswell said. “I mean, we are dealing with people week to week, and we’re also dealing with people at the point of crisis where they’re in hospitals and in hospice and they’re having to deal with major life issues.”

In fact, coordinating Obamacare enrollment efforts with faith leaders could be great news for another population that has largely been ignored in all the hubbub and politics of the expansion: Americans who already qualify for the program, but have never enrolled. In a 2006 report, the Commonwealth Fund estimated that 62 percent of Medicaid or CHIP-eligible children were not enrolled in either program, and 66 percent of Medicaid-eligible low-income parents were not enrolled.

Much of that discrepancy has to do with underwhelming state outreach efforts stemming from a lack of adequate funding, as well as the reality that many Medicaid-eligible populations simply don’t know they have the resource available to them. “Even in states that have more of a commitment to bringing new populations in, they don’t have the budget to do outreach and take out ads,” said Melinda Dutton, a partner at a health consulting firm assisting states with Obamacare implementation, in an interview with American Medical News.

But with the renewed national push for Medicaid enrollment ramping up this year, some health advocates hope that these previously unenrolled Americans will get swept up in the effort and “come out of the woodwork.” That’s where faith leaders are crucial to the undertaking, since they have greater access to the rural or isolated communities that Medicaid may have overlooked.

For example, the homeless — or those on the cusp of entering transitional housing programs — often do not enroll in Medicaid due to barriers such as a lack of proper identification or a Social Security card. These populations also tend to distrust government institutions — but faith leaders and community organizations could help walk them through the process in a way that the government can’t, helping secure their medical stability. And with over 25 million Americans expected to gain coverage under Obamacare in the coming decade, state, federal, and public health officials will need all the help that they can get.

In light of Republican-led states’ entrenched opposition to Obamacare’s Medicaid expansion, safety net hospitals around the country have expressed fears that they could go bankrupt as their government funding gets cut. On Monday, the Center for Medicare and Medicaid Services (CMS) announced that it would help these embattled hospitals by paring back planned cuts to their federal reimbursements.

In an attempt to cut government health expenditures, Obamacare included fairly deep cuts to so-called “disproportionate share” hospitals’ (DSHs’) — safety net facilities that cater mostly to the poor and uninsured — reimbursement payments. These cuts were intended to be offset by an influx of newly-insured Americans covered under the states’ expanded Medicaid programs.

But since the Supreme Court ruled the expansion optional, red states with a large number of low-income and uninsured residents have largely refused to take part in the Medicaid expansion, thereby creating a disastrous funding problem for safety net hospitals in these states. The CMS’s new proposed regulations represent an effort to avert those disastrous cuts as states get their acts together:

The Centers for Medicare & Medicaid Services proposed on Monday that for the next two years, the DSH dollars be reduced based partly on a state’s percent of uninsured residents (states with the lowest percent of uninsured receive larger reductions). CMS also seeks in the proposal to protect state DSH funding that is used to increase coverage under Medicaid demonstration waivers. [...]

“… since some states have yet to decide whether to expand Medicaid, this proposed rule will not discourage expansion, nor will it penalize hospitals in those states that have yet to make a decision,” [Rick Pollack, executive vice president of the American Hospital Association,] said.

However, CMS’s new proposal is a funding band-aid, not a permanent fix. The far more responsible and efficient way to take the heat off of America’s safety net hospitals — while securing low-income Americans’ medical and financial well-being — would be for highly uninsured states to accept the health law’s generous funding to expand Medicaid.

In fact, that’s exactly why some GOP governors such as Arizona’s Jan Brewer and Florida’s Rick Scott have reversed course and decided to endorse the Medicaid expansion — because hospital associations in their states have been warning that noncompliance in the face the upcoming payment cuts would cost them tens of billions of dollars and possibly force them out of business, leaving millions of America’s poor without recourse for medical care. Unfortunately, not all Republican state leaders and legislators seem to be swayed by that argument, forcing the CMS to take action and stave off safety net hospitals’ fiscal ruin.

But seeing as even the GOP governors who have endorsed expansion are struggling to convince skeptical legislators in their own party, the temporary fix is crucial to making sure that safety net hospitals — and the millions of poor Americans who rely on them — don’t end up as the collateral damage of a political fistfight over Obamacare. Arizona, Florida, Texas, and Louisiana — four GOP states that appear increasingly unlikely to expand Medicaid this year — have close to 12 million uninsured residents alone, approximately half of whom live below 138 percent of the Federal Poverty Level (FPL) and would likely gain Medicaid coverage under the expansion.

Kentucky Gov. Steve Beshear (D) announced on Thursday that he would accept federal money to expand his state’s Medicaid program under Obamacare. That brings the total number of states participating in the optional expansion up to either 22 or 18 (plus the District of Columbia) — depending on the actions of some state legislatures that are still debating the issue.

According to a press release from Beshear’s office, the governor called the move “the single-most important decision in our lifetime for improving the health of Kentuckians” and something that is “in the best interest of the Commonwealth and its citizens.” He also stated that an analysis of the expansion’s costs revealed that non-participation would be mean losing money for the state, echoing the fiscal argument made by West Virginia Gov. Earl Ray Tomblin (D) last week.

Beshear certainly has his numbers right. According to the Kaiser Family Foundation, Medicaid expansion will cut Kentucky’s high uninsurance rate by over 55 percent, and the price of noncompliance could be as high as $40 million by 2021. Considering upcoming cuts to safety net hospitals that serve poor residents and the reality that nearly one in three Kentuckians living below 139 percent of the Federal Poverty Level (FPL) is uninsured, that would have proven to be an unaffordable cost from both a fiscal and a public health standpoint.

What’s less clear is how much difficulty Beshear will have with gaining the support of lawmakers in a state that has elected ardent Obamacare opponents like Sens. Mitch McConnell (R) and Rand Paul (R). Democrats hold an 11-seat edge in Kentucky’s state House, while Republicans hold an 11-seat edge in the state Senate. Convincing those 11 Republican state senators could be difficult, considering that several other GOP governors in highly uninsured states are still battling their own party members to cooperate with the health law’s Medicaid expansion.

Texas lawmakers have until midnight on Thursday to negotiate a deal on the 2014-2015 state budget before the current legislative session ends. But they may find themselves in town for a bit longer if some Tea Party lawmakers in the state House have their way and force a special legislative session over a Republican-backed rider regarding Obamacare’s Medicaid expansion — even though the amendment wouldn’t actually expand Texas’ Medicaid program, but simply “open the door to discussions with the federal government to expand health care coverage for the state’s poorest adults.”

The threats from Texas Tea Partiers make it even more unlikely than it already was that the Lone Star State will pass anything resembling a Medicaid expansion — or even future promises to simply talk about the issue — this year. As Texas Republicans — who introduced the rider — point out, the provision is simply a declaration that state and federal officials will discuss how to help the state’s poorest residents gain coverage in a way that hews to conservative, “free market principles” regarding health entitlements in light of upcoming cuts to safety net hospitals and Texas’ massive poor and uninsured population. But those arguments have failed to sway some in the Tea Party caucus, who view any talk of Medicaid at all as a sell-out to President Obama’s landmark health reform law:

“If the budget expanded Medicaid, conservatives in the House would vote the budget down,” said state Rep. Van Taylor, a Tea Party favorite from Plano. He said conservative Republican members of the House are “absolutely prepared to go to the mat” and return for multiple special sessions to prevent any semblance of Medicaid expansion.

State Rep. John Zerwas, R-Simonton, said House Bill 3791, which he filed to present the Legislature with an alternative way to expand health coverage to the state’s poorest adults without expanding Medicaid, would probably not move out of the lower chamber by the House’s midnight Thursday deadline, therefore the rider was one of few — if not the only — remaining legislative vehicles for the Legislature to weigh in on the issue.

“If people took the time to read the rider they would recognize that it’s not a Medicaid expansion,” he said. “They would understand clearly that it is a lot of, frankly, conservative principles.”

In fact, HB 3791 — a GOP alternative to Obamacare’s Medicaid expansion that would have covered Texas’ poorest by giving them subsidies to buy private insurance — was already doomed to fail in the House. This rider is simply a last resort that promises future negotiations on the issue. It actually also endorses extremely regressive approaches to expanding the safety net, including possibly block-granting the state’s Medicaid program. But, as the debate over Obamacare has become increasingly disconnected from reality, some members of the Texas Tea Party are willing to hold the state’s entire budget hostage over a measure endorsing policies that they have historically supported.

While this recent infighting is something of a new low in the Medicaid expansion debate, GOP hypocrisy regarding the health reform law certainly isn’t. Receiving federal funding in exchange for expanding and privatizing Medicaid programs — which the Obama Administration has signed onto — is usually a GOP-endorsed policy. In fact, Texas Gov. Rick Perry (R) struck a massive deal with federal officials in 2011 allowing him to move close to a million Medicaid beneficiaries into private, managed care. Perry heralded the move at the time, but has refused to accept an expanded version that same deal now that it’s a priority for the Administration and necessary for effective Obamacare implementation.

Only 35 percent of Texans living below 139 percent of the Federal Poverty Line (FPL) are covered by the state’s Medicaid program. 43 percent are uninsured.