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.

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.”

Texas Gov. Rick Perry (R) and the state’s two Republican senators, John Cornyn and Ted Cruz, joined forces at the state capitol on Monday afternoon to reiterate their opposition to expanding the Medicaid program under Obamacare. Despite the fact that Texas could add about 1.5 million low-income people to its Medicaid rolls if lawmakers opted to expand the program, the state’s GOP leaders still refuse to do so.

“Seems to me April Fool’s Day is the perfect day to discuss something as foolish as Medicaid expansion, and to remind everyone 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,” Perry said of the health reform law’s initiative to ensure that poor Americans have access to the medical care they need by standardizing Medicaid eligibility levels across the nation.

More than 25 percent of Texans don’t have health care, one of the highest rates of uninsurance in the United States. That’s partly because the state’s Medicaid program is currently one of the most restrictive — requiring a family of three to earn less than $5,000 per year, far below the federal poverty line, to qualify for public health insurance. But the Republicans in the state want to make it clear that’s not going to change anytime soon.

Although eight other GOP governors have now endorsed the health law’s optional Medicaid expansion, the GOP lawmakers in Texas are happy to buck that trend. “I am proud that Gov. Perry and other Texas leaders are standing strong to oppose Medicaid expansion under Obamacare, while so many other states are giving in,” Cruz said at Monday’s press conference. Earlier in the day, Cruz suggested that Obamacare’s Medicaid expansion is so expensive that it will prevent states from fully funding their prison systems and keeping violent criminals off the street.

Not everyone in Texas agrees with the Republican Party’s decision to reject Obamacare’s Medicaid expansion, however. A counter event — spearheaded by Rep. Joaquin Castro (D-TX), and his identical twin, San Antonio Mayor Julián Castro (D) — followed the governor’s press conference, as advocates for health care reform spoke out about the importance of expanding Texas’ social safety net. The Castro brothers were joined by a diverse coalition of faith-based organizations, labor groups, the Texas Hospital Association, and other Democratic lawmakers, all of whom have been lobbying for Medicaid expansion over the past several months.

During an appearance on Greta Van Sustern’s Fox News program Tuesday evening, Texas Gov. Rick Perry (R) reiterated his well-known opposition to all things Obamacare, particularly the reform law’s optional expansion of the public Medicaid program for low-income Americans.

But while defending Texas’ rejection of the expansion, Perry turned to a rather odd argument to justify his decision — claiming that the Obama Homeland Security Department’s release of thousands of nonviolent immigrants from detention centers somehow proves that the federal government cannot be trusted to fund states’ Medicaid expansions:

VAN SUSTEREN: All right, now, let me turn the question to you. You mentioned Medicaid expansion, and you had said, I think as long ago as July, that you were not going to accept the offer to expand Medicaid, which is the federal government pays for. Governor Rick Scott of Florida has changed his mind. Governor Chris Christie — I don’t know if he changed his mind, but accepting that Medicaid. What do you say to — why do you think those two governors are doing it? What’s — and why aren’t you?

PERRY: Well, we looked at this rather intently. The legislature just over the course of the last 24 hours in Texas and the Republican caucus overwhelmingly support the position of not expanding Medicaid. It is a broken system. We have asked the federal government for years to allow us the flexibility to be able to put these programs into place, but the fact is, it’s a broken system. It’s going to cost trillions of dollars to implement this program. But Texans are not going to be blackmailed into expanding a program that then the federal government is telling us they’re going to give us all this free money. Greta, they can’t keep criminals in jail today, much less be able to have extra money to pass out to these states. So the idea that money is going to be available for expanded Medicaid is a pipe dream.

Even aside from the fact that Perry’s argument constitutes a total non sequitur, his portrayal of DHS’s actions is also highly misleading. Earlier this week, DHS Secretary Janet Napolitano — flanked by two former Republican DHS secretaries — explained that the vast majority of the releases were a result of routine movement in detention facilities and unrelated to any government-induced fiscal policy, and that the best method of ensuring border security would be for Congress to pass comprehensive immigration reform.

Perry also repeats a common right-wing talking point that the federal government’s promise to provide the funding for states’ Medicaid expansions is too good to be true, and that the Obama Administration will eventually be forced to go back on its word. But the historical data shows that Perry is dead wrong. The federal government has honored its obligations to funding state Medicaid programs with remarkable consistency, even as the public insurance system has enrolled millions of additional Americans since its inception. The only exception to this occurred between 2009 and 2012, since the stimulus package passed in response to the 2008 global financial crisis “included a deliberate and temporary boost to Medicaid funding to help states buffer against the recession” and “was never meant to be a permanent increase to Medicaid federal match rates” — unlike Obamacare, which is intended to be exactly that.

Despite the fact that more than 25 percent of Texas’ population is uninsured, Gov. Rick Perry (R) has rejected Obamacare’s optional expansion of the Medicaid program, a move that will deny health coverage to more than 133,000 low-income Texans. In order to pressure him to change his mind, a diverse coalition of community leaders in Dallas — including state lawmakers, interfaith groups, and hospital officials — has partnered to advocate for the Medicaid expansion, arguing that Texas must accept federal funding to extend insurance to thousands of the state’s impoverished residents.

And their work is paying off. Dallas County officials will adopt a resolution today that encourages state lawmakers to expand Medicaid, after El Paso officials adopted a similar resolution yesterday. The coalition hopes that the momentum in support of the optional Obamacare provision will lead other Texas counties to follow suit:

“We’re doing his across the state. The resolution is our strategy…to put pressure on the governor and the Legislature to pass Medicaid expansion,” said Willie Bennett, lead organizer with the Dallas Area interfaith coalition, which helped write the resolution on Medicaid expansion that Dallas County plans to adopt on Tuesday. He said their organization helped craft a similar resolution that the El Paso County Commissioners Court adopted on Monday, and is working with other major counties to also pass resolutions.

Bolstered by Dallas County’s impending decision, the Texas Organizing Project, an advocacy group that has organized hundreds of Texans to support expanding Medicaid, plans to send coalition members to county meetings in Bexar, Harris and Hidalgo counties on Tuesday to testify in favor of local government officials adopting similar resolutions to support Medicaid expansion.

“Working uninsured [Texans] are leading the fight. These are everyday people who work, some of them six days a week, but can’t afford health insurance,” said Durrel Douglas, a spokesman for the Texas Organizing Project.

Texas’ health care system is ranked as the worst in the nation, and the state’s Medicaid program is currently one of the most restrictive — requiring a family of three to earn less than $5,000 per year, far below the federal poverty line, to qualify for public health insurance.

Officials in some of Texas’ largest counties have been frustrated with their governor’s refusal to cooperate with Obamacare for months. Back in August, some county officials investigated the possibility of pursuing their own Medicaid expansions, even if Perry insisted on withholding federal funds to implement a state-wide expansion. But now that the Obama Administration has clarified that states may not set up partial expansions, they’re once again at the mercy of their stubborn governor.

Nevertheless, the Medicaid advocates in Texas are growing, and they hope to change the tide. The wide range of groups involved in the push for the state’s Medicaid expansion include the Texas Hospital Association, the Texas Medical Association, and an interfaith coalition that includes the Texas Catholic Conference.

Texas officials were so insistent on defunding Planned Parenthood, they dismantled the state’s federally-funded Women’s Health Program — a network of doctors that provide care for low-income women — so they could relaunch a new program excluding the national organization. But targeting Planned Parenthood comes at a steep price for the women seeking preventative care in Texas. Even though the state initially claimed their new program would have 3,500 participating providers for women to choose from, that list has now shrunk by nearly 1,000, leaving women in the state with even fewer options for their doctors.

Texas relaunched its state-run Women’s Health Program at the beginning of January. Even though the state has always maintained its new program will be able to meet the same demand as the old one did, that hasn’t proven to be the case so far. The first list of providers the state provided was inaccurate and confusing. And now that the state has released a revised list, the Texas Tribune reports it’s significantly smaller than promised:

The Texas WHP replaced the federal Medicaid WHP on Jan. 1. The program’s Affiliate Ban Rule, which prohibits providers associated with abortion clinics from participation, forced the exclusion of 50 Planned Parenthood clinics that participated in the former Medicaid program. Without Planned Parenthood, women’s health advocates have argued that the state will not be able to adequately serve low-income women enrolled in the program.

The HHSC had previously stated that the Texas WHP had 3,500 participating providers, roughly 1,000 more than the number of providers that participated in the former Medicaid WHP. That list has shrunk to 2,448 doctors and clinics, as 965 providers said they would not accept WHP patients, despite being certified for the program. The contact information for 700 other providers has also been updated on the state’s website.

From the beginning of Texas’ crusade against Planned Parenthood, there have been questions about the state’s ability to effectively relaunch its health program without federal funding. Last year, Gov. Rick Perry (R) convened a smoke-and-mirrors press conference to announce that the new Women’s Health Program was ready to go — even though it wasn’t.

Up to 50,000 women are being forced to search for new doctors this year now that they can no longer get their care at Planned Parenthood. To keep up with the increased demand from new patients, other providers in the Women’s Health Program may be forced to take up to five times the number of their usual Medicaid patients.