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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One congressman is so vehemently opposed to Obamacare that he’s willing to sacrifice his own health insurance in order to make a point.

Rep. Mark Amodei (R-NV), who entered Congress in 2011, was asked last week prior to the House’s vote to repeal Obamacare whether he would be giving up his own government-sponsored health insurance. “Happy to,” Amodei replied.

QUESTIONER: Will you give up your own congressional health care after voting to repeal tomorrow?

AMODEI: Happy to. Have a nice day.

Watch it:

The Federal Employees Health Benefit Program (FEHBP), which covers all federal workers, is similar in many ways to Obamacare. For example, both provide tax-payer subsidized coverage and allow enrollees to choose private insurance plans from a highly-regulated market.

ThinkProgress reached out to Amodei’s office to see whether he has dropped his government insurance plan yet, but they have yet to respond.

Unless the Nevada congressmen is fortunate enough to attain insurance elsewhere, whether though a spouse or a private insurance plan, Amodei’s decision to give up FEHBP is financially ill advised. Giving up health insurance means he’s more likely to forgo preventive care and would have to pay large medical bills out of pocket or, if he can’t afford them, pass those bills onto taxpayers.

Still, giving up government health insurance was briefly in vogue among Tea Party Republicans on Capitol Hill. At least half a dozen GOP congressmen personally gave up government-sponsored health care in 2011 after running on a repeal-Obamacare platform.

There’s new evidence to suggest that Obamacare is impacting the health industry for the better by successfully encouraging a greater emphasis on primary care. Ensuring that Americans are receiving regular preventative care is an important tenant of the health law, since it can ultimately help lower costs by preventing people from delaying medical treatment until they’re already very sick.

For the first time ever, Americans are now spending more money on primary care physicians than they are on specialists, according to a new survey by the physician recruiting firm Merritt Hawkins. In what Merrit Hawkins’ president referred to as a “seismic shift” in medicine, primary care doctors are now the greatest source of revenue for the hospitals where they work:

For the first time, primary care physicians are driving more revenue on a per-doctor basis to hospitals than are specialists, according to a survey of hospital chief financial officers by physician recruiting firm Merritt Hawkins. It’s expected that this result is not a fluke, but a reflection of the growing emphasis on primary care by hospitals and the health care system in general. [...]

Merritt Hawkins said there were major shifts in the health care system from 2010 to 2013 that put pressure on all physicians, particularly specialists. One major factor is the 2010 Affordable Care Act, which has several pieces that put more onus on primary care to cut overall costs and keep patients healthy, especially those with chronic conditions or who otherwise would delay care until they are seriously ill. The rise in primary care contributions came as overall per-physician revenue for hospitals fell — from more than $1.5 million in 2010 to more than $1.4 million in 2013. It’s the lowest median in the 11 years Merritt Hawkins has conducted the survey.

As more than 25 million previously uninsured Americans gain coverage under Obamacare, the trend toward primary care is expected to continue. Those people likely avoided expensive medical treatment while they didn’t have insurance, but they’ll have the opportunity to seek regular check-ups once they become covered in 2014. In order to tackle the influx of Americans who will require primary care services, there will be opportunities for nurse practitioners to expand their role as health care providers.

As state and federal officials work toward the full implementation of Obamacare, politicians on both sides of the aisle have blasted the ongoing effort as a “train wreck.” But there’s mounting evidence to suggest those concerns are overblown. Although there’s still more work to be done to prepare for the state-level insurance marketplaces that will open to the public in 2014, much of the health reform law is already in effect — and it’s already having a demonstrable impact on the United States’ health industry. In addition to the shift to primary care, Obamacare has also already ensured that health care will be cheaper for many Americans by forcing private insurers to lower their premiums.

Doctors are reluctant to give nurses more authority to treat patients, according to findings in a New England Journal of Medicine study released on Wednesday. But doctors’ skepticism about nurses having expanded roles isn’t based on the facts — and it ignores the reality that nurse practitioners must take on such responsibilities if health care reform is to succeed.

The new study finds that many doctors don’t trust nurses to lead patient-centered “medical homes,” with only 17 percent of surveyed primary care physicians viewing it positively. “Medical homes” are arrangements encouraged by Obamacare in which nurses, doctors, pharmacists, and specialists work together to provide patients with better and more efficient care in a unified setting.

There is also a striking chasm between doctors and nurses on the issue of nurse practitioners’ ability to provide safe, quality patient care:

When researchers asked whether they felt the quality of care provided by physicians in exams and consultations was higher than that provided by nurse practitioners, more than 66 percent of doctors agreed, while 75 percent of nurses disagreed.

Doctors also overwhelmingly disagreed with many nurses’ position that they should receive the same level of pay as doctors for performing similar services.

But this position is an untenable one in the era of Obamacare, with more than 25 million Americans expected to gain health coverage in the coming decade. Since the bulk of these Americans are expected to consume primary care — rather than specialty — services, it’s important that the U.S. medical system have enough medical workers to serve them. And there simply aren’t enough primary care doctors to tackle that burden on their own.

Instead, nurse practitioners will have to take on additional responsibilities. There’s no reason to suspect that this will compromise patient care quality — in fact, multiple studies have shown that the quality of care that nurse practitioners provide for acute primary care is on par with doctors. One randomized trial comparing nurses’ versus doctors’ ability to manage complex care regimens for HIV-positive patients receiving antiretroviral therapy also found no evidence of professional inferiority. As David Hebert, CEO of the American Association of Nurse Practitioners, told Kaiser Health News, “[N]urse practitioners have been practicing safely and providing great outcomes for decades.”

Doctors — and patients — would be well served by an expanded role for nurse practitioners. Primary care doctors tend to be concentrated in urban areas, creating a major barrier to rural and isolated communities’ access to basic medical services. But nurses are more numerous and could have greater access to such populations, making them ideal candidates for heading medical homes and seeing to the day-to-day aspects of patient care.

A Senate Republican has seized on the growing controversy surround the IRS scandal to introduce a bill that would effectively repeal a huge chunk of the Affordable Care Act and significantly increase health care costs for millions of Americans.

Sen. Dean Heller’s (R-NV) “IRS Accountability Act” would prohibit “the IRS from receiving any ObamaCare funding that would otherwise be used for implementing the massive healthcare law,” preventing the agency from enforcing the law’s individual health care mandate, determining eligibility for affordability credits, and collecting taxes to help pay for the coverage expansion.

“Nevadans are already concerned about ObamaCare, so the fact that Congress could hand over even more power to an agency under intense scrutiny to enforce the health care law is deeply concerning,” Heller said in a statement. “The ‘IRS Accountability Act’ suspends funding for new ObamaCare IRS agents because right now we can’t trust the IRS to do its job.”

By 2014, the health care law will require the agency to assess fines on individuals who can afford to purchase health care coverage, but choose not to, and distribute tax subsidies for families who make no more than four times above the federal poverty line, approximately $94,200 for a family of four. Should Heller’s bill become law, the government wouldn’t be able to collect the penalties or pay out subsidies. It would also struggle to capture revenues from fees on medical devises, health care insurers and high-cost plans.

The penalty for going uninsured — which will be gradually phased in from 2014 to 2016 and then increase annually by the cost-of-living adjustment — is designed to encourage young and healthy people to buy coverage and spread the cost and risk of coverage across a wider population, thus lowering premiums. Though it’s unclear how many fewer people would purchase insurance if they were not penalized for not doing so, a 2012 study from the Urban Institute indicated that without a mandate, “nongroup premiums overall would increase by roughly 10 percent with high exchange participation and by 25 percent with low participation.”

Heller’s office did not respond to requests for comment.

For the 37th time since 2011, House Republicans will hold a vote to repeal Obamacare on Thursday, bringing the total cost of all of their failed repeal votes to roughly $55 million in taxpayer money, according to one estimate.

Last year, CBS News calculated that the number of hours spent on 33 repeal votes — then roughly 80 hours, or two full work weeks — cost taxpayers an estimated $48 million. Since then, Republicans have held three more votes (another $4.5 million) and will add another $1.5 million with their latest.

At a time when lawmakers have implemented $85 billion in across-the-board cuts on top of $1.5 trillion in spending cuts over the next decade, no dollar can be spared. And the country has serious health-related needs that could use funding. Here are some better health care uses for the more than $50 million these symbolic votes against the Affordable Care Act have wasted:

1. Restore cuts from sequestration to Title X family planning programs and Title V maternal and child health services. The National Women’s Law Center calculates that a 5 percent cut to the budgets of each program will reduce them by $15 million and $32.5 million, respectively. Rather than voting to repeal a bill that expands women’s access to preventative services, the House could use the money to expand them.

2. Double the Department of Justice’s budget for sexual assault services, which has currently been authorized a $50 million budget. The program gives money to states so that they can support rape crisis centers and other nongovernmental organizations that provide direct intervention, core services, and other assistance to the victims of sexual assault. Current funding is inadequate, as some states receive less than $300,000 and many programs lack the resources to meet victims’ needs.

3. Grant a request for $50 million to train 5,000 new mental health professionals as part of a new initiative to expand mental health treatment and prevention services. This proposal came in the wake of the Sandy Hook shooting to address gaps in the mental health system.

4. Help states implement paid leave policies. President Obama included a $50 million State Paid Leave Fund in his 2011 budget to provide start-up support for states that want to enact paid leave for workers. More than 40 percent of workers don’t have access to paid sick leave, heading to work when they or their family members experience an illness, but this funding could help give them a better option.

The current Congress is on track to be the most unproductive since the 1940s, but still has time to hold votes that won’t result in actual legislative change. There are many other priorities lawmakers could focus on instead and better ways to spend taxpayer dollars.

During an interview with World Net Daily, former Republican presidential aspirant Rep. Michele Bachmann (R-MN) raised the question: could Obamacare allow the IRS to “deny or delay” conservatives’ access to medical care?

Bachmann’s musings come on the heels of an ongoing IRS scandal centering on the agency’s improper scrutiny of conservative political groups. While right-wing commentators and politicians are already using the incident to smear the health law by raising questions about IRS access to Americans’ private medical data, Bachmann took things one step further:

Since the IRS also is the chief enforcer of Obamacare requirements, [Bachmann] asked whether the IRS’s admission means it “will deny or delay access to health care” for conservatives.

At this point, she said, that “is a reasonable question to ask.” […]

[S]hould Americans fear their government may try to harm them if they are conservative?

“It now is an entirely reasonable question for the American people to ask,” she said. “Will Obamacare be so politicized and misused?”

The IRS has been processing information about Americans’ health care for decades, since approximately 160 million Americans write off their tax-deductible employer-provided health benefits each year. There has been no evidence of any kind of privacy impropriety in all of that time.

Under Obamacare, the IRS will be responsible for determining whether or not Americans have insurance so that it can use household income data to provide consumers with government subsidies to buy health coverage. The agency will not determine if, when, or what benefits are provided to Americans.

This isn’t the first time Bachmann has made outlandish comments about Obamacare or health care in general. The congresswoman has previously asserted that Obamacare will “literally” kill people and propagated debunked conspiracy theories claiming that the HPV vaccine causes young girls to become “sexually promiscuous.”

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.

Last week, House Majority Leader Eric Cantor (R-VA) promised to schedule the first full Obamacare repeal vote for this legislative session. That vote, which will likely come on Thursday, will give freshman Republicans in the 113th Congress the opportunity to cast their own purely symbolic vote against health care reform. It will also mark the 37th time that the GOP-controlled House has voted to get rid of the health law.

And, as the New York Times points out, House Republicans’ obsession with repealing Obamacare becomes even more apparent when the amount of time they’ve devoted to that issue is calculated as a percentage of the total time they’ve spent on the floor:

The repeal vote, which is likely to occur Thursday, will be at least the 43rd day since Republicans took over the House that they have devoted time to voting on the issue.

To put that in perspective, they have held votes on only 281 days since taking power in January 2011. (The House and Senate have pretty light legislative loads these days, typically voting only three or four days a week.)

That means that since 2011, Republicans have spent no less than 15 percent of their time on the House floor on repeal in some way. [...]

Michael Steel, [Speaker John Boehner's spokesman], said that spending 15 percent of their time on the issue was hardly a waste for Republicans. “Given that the bill amounts to a takeover of roughly 15 percent of the American economy,” he said, “that sounds about right.”

By some earlier estimations, Republicans in the 112th Congress wasted about 90 hours and $50 million dollars on their multiple failed efforts to get rid of the health reform law. This new Congress is shaping up to be no different. Even though Republicans have admitted they have lost on Obamacare, and are even acknowledging that their future repeal efforts will fail, they have continued to block legislative efforts to amend the health reform law in favor of stubbornly opposing it altogether.

The House conservatives who are focused on pushing the leadership further to the right have been particularly intent on scheduling a full Obamacare repeal vote this session. “It’s something that we wanted to move up on the list of priorities,” Rep. Steve Scalise (R-LA) told the New York Times. “And I’m glad they listened to us.”

Successfully repealing Obamacare would put more than 30 million Americans’ health coverage at risk, as well as increase the national deficit by billions. It would also ignore the opinion of the majority of the American public, who think that implementing Obamacare should be a top priority in their state. At this point, now that the bulk of the health law has already gone into place, most Americans aren’t interested in defunding it or repealing it altogether — they would rather tweak it to make it better.