Florida Gov. Rick Scott (R), an ardent Obamacare opponent, surprised health care reform advocates earlier this year when he endorsed expanding his state’s Medicaid program. But the governor can’t single-handedly add more low-income residents to the Florida’s Medicaid rolls; the proposal still needs the support of the GOP-controlled legislature, which has been fighting over it for the past several months. And now that the state’s legislative session has come to an end, time has run out for the estimated 1.3 million Floridians who stood to gain health insurance under Obamacare’s Medicaid expansion.

On Friday, the legislature concluded without passing a budget that includes funding for expanding Medicaid. That means Florida won’t expand Medicaid in 2014 unless lawmakers convene a special session sometime later this year. Democrats in the state are calling for that special session to focus on pushing through a compromise, but the Republican-dominated legislature may not comply. The decision to refuse the expansion will leave about one million Florida residents uninsured.

As Wonkblog’s Sarah Kliff notes, this situation isn’t unique to Florida. In other red states, the Republican governors who have chosen to endorse Medicaid expansion are also struggling to get the support they need from the other members of their party to advance the policy:

This isn’t a phenomenon reserved to Florida. In Ohio, Gov. John Kasich (R) is having trouble moving the Medicaid expansion he supported through the state’s Republican controlled-legislature. Similar fights are playing out in Arizona and Michigan, where Republican governors find themselves in the relatively odd position of trying to sell Obamacare to state legislators of their own party.

In a way, this is a bit surprising. No one ever expected to hear Scott extoll the benefits of President Obama’s signature legislative accomplishment. That being said, the Medicaid expansion is a really big deal for state budgets — the budget that Scott is charged with overseeing. If his state had participated in the Medicaid expansion, the Urban Institute estimated it would bring $66 billion of federal funds into the state over the course of a decade.

That same burden doesn’t rest so heavy on state legislators. States and hospitals tend to cover much of the country’s uncompensated care and unpaid medical bills. Meanwhile, state legislators have faced intense pressure over this vote. In Ohio, my colleague Sandhya Somashekar reported on one group that went door-to-door collecting signatures from voters pledging to thwart reelection efforts should lawmakers there vote to expand Medicaid.

The politicized in-fighting over Obamacare has pitted governors against legislatures across the country, as many Republicans still refuse to cooperate with health reform no matter what the cost. But for the residents in states like Florida, that political reality comes with especially significant consequences.

Florida, where about one in five people lack health care, has one of the highest rates of uninsurance in the nation. Previous studies have estimated that it’s one of the states that would benefit the most from the health reform law’s Medicaid expansion provision. Hospital groups and faith leaders in the state have both lobbied for expanding Medicaid, which they characterize as a “pro-life” program. Nevertheless, even though Rick Scott was able to put aside politics to prioritize health care for low-income Floridians, his fellow Republican lawmakers haven’t been able to do the same.

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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The GOP-controlled Florida state house on Friday passed a Medicaid “expansion” bill that would substantially burden the state’s budget by rejecting any federal funding. It would open up private insurance access to a very select pool of Florida’s low-income residents — but it could force these vulnerable Americans to forgo care, despite their new coverage, by giving them insufficient subsidies and making them choose between private high-deductible health plans (HDHPs) that also come with costly premiums.

Unlike its companion bill in the Senate — which has been endorsed by both Gov. Rick Scott (R) and the Obama Administration — the House’s bill would expand coverage to a mere one-tenth of the 1.1 million poor Floridians who would have gained access under a more expansive effort. That’s because the bill only addresses Americans living at or below the Federal Poverty Level (FPL), instead of Obamacare’s more ambitious limit.

Now that the bill has passed, a showdown between the House and Senate is likely. Although both bills would privatize Florida’s Medicaid program, the Senate’s version would insure all poor Floridians up to 138 percent FPL. The House version, on the other hand, will concentrate on extending insurance to poor single moms, poor working parents, and disabled adults by giving them a flat $2,000 per year subsidy — but would not extend coverage to poor working adults in general. Although Republicans insisted the pared down bill was necessary to contain rising health costs, critics argued that it is unfair to ask the poorest Americans to pay over three times the monthly premium as state workers and legislators, pointing out that there is bipartisan support for the Senate’s alternative bill:

The House plan would use $237 million in state funds to give recipients $2,000 a year to choose their own private insurance plans. The plans would require a $25 monthly premium and likely have high deductibles, which Democrats said many families would not be able to afford.

In contrast, House members covered by the state insurance plan spend $8 a month.

“There’s very little you can buy,” said Rep. Mia Jones, D-Jacksonville. “This population will not be able to take this product that has been crafted for them and not be able to do anything of value with it.”

House Democratic Leader Perry Thurston warned that members were missing a chance for bipartisanship, noting the Senate had already put aside their differences.

“We have a governor who has disagreement with the president of the United States but they came to a bipartisan resolution and put aside those differences,” Thurston said. “Why? Because of the importance of saving lives.”

As Jones points out, since this bill would provide Floirida’s uninsured with insurance that they still won’t be able to use, the $237 million price tag is largely a waste. The average annual deductible in HDHPs has been rising steadily as more employers rely on them, ranging anywhere from $1,100 for an individual to $2,500 for a family in 2012. By contrast, the average annual out-of-pocket health care costs for American households is expected to exceed $3,000 by 2014. So the $2,000 annual subsidy wouldn’t end up going very far at all. This would present a problem for any family trying to afford health coverage — but for the particularly vulnerable populations that the Florida House’s bill seeks to cover, it could be catastrophic. Low-income Americans have specialized health care needs that, in many cases, are simply not covered by cheaper private health plans.

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Former Florida Gov. Jeb Bush (R) appeared on MSNBC’s The Daily Rundown on Tuesday morning to discuss, among other things, a potential presidential run in 2016. And his future political aspirations are already forcing him to choose his words carefully. Even though Bush is an ardent opponent of Obamacare’s Medicaid expansion in private, he wouldn’t go on the record to oppose Gov. Rick Scott’s (R-FL) recent decision to extend health coverage to an estimated 1.3 million low-income Floridians.

Obamacare’s state-level Medicaid expansion is popular with the public, and an increasing number of GOP leaders — including Florida’s — are finally awakening to the reality that accepting federal funds to expand Medicaid is the right move for their constituents as well as for their state budgets. That shift is forcing anti-Obamacare politicians like Bush to mask their opposition to expansion. When host Chuck Todd asked Bush whether he agreed with Scott’s new position on Medicaid expansion, the former governor claimed he’s been too “busy” to form an opinion on the subject:

TODD: Did you think it was the right decision? Would you have made that call?

BUSH: Anytime you have a chance to advocate reform, you should. So Medicaid needs to be reformed. If you’re going to expand it by 50 percent, it sure better be a dramatically different system. And in Florida, there’s a waiver that has been approved that could be that reform — that expands on the reforms that I had a chance to advocate when I was governor. So if the focus is on making Medicaid work for people and that it won’t create this out year costs that people anticipate, that somehow the reform will yield a better result, then okay. Then give him credit. But I haven’t heard that yet –

TODD: You’re not there yet.

BUSH: I guess I’ve been busy, I haven’t been watching the specifics of it. If that’s the case, kudos to the governor. If it isn’t, then he’s put the state in a precarious position three or four years out.

It’s likely not a politically smart move for Florida’s former governor to publicly come out in opposition to extending health coverage to low-income residents in his state, which has one of the highest uninsurance rates in the nation. As of two weeks ago, however, Bush had made up his mind enough to privately pressure Florida lawmakers to oppose expanding Medicaid — urging them to stand in direct opposition to Rick Scott and come up with an alternative to expansion. Those efforts may have paid off. The state’s GOP-controlled House of Representatives voted to reject Medicaid expansion on Monday, effectively stalling reform.

Bush demurred on his personal position on Scott’s decision, but he did indicate his support for Florida’s Medicaid waiver — which is essentially a proposal to shift the program’s beneficiaries toward private managed care. If Bush does begin paying more attention to the specifics of health policy, he may be interested to learn that Florida’s push to privatize the public program would likely be even more expensive than accepting Obamacare’s traditional expansion, since Medicaid is currently much cheaper than private insurance.

The GOP’s potential presidential candidates are split on the issue of Medicaid expansion. New Jersey Gov. Chris Christie agreed to expand Medicaid just last week — a position that may have landed him in hot water with the conservative establishment — but Louisiana Gov. Bobby Jindal remains opposed it, and Wisconsin Gov. Scott Walker has rejected Obamacare’s Medicaid expansion in favor of a risky proposal that may end up providing his state’s poor residents with a lower quality of coverage.

Florida Gov. Rick Scott (R), a former hospital CEO and ardent Obamacare critic, announced at a press conference Wednesday evening that he will accept Obamacare funding in order to expand his state’s Medicaid program for low-income Americans. The move comes after Scott secured a waiver to privatize the public insurance program.

The decision represents a marked departure from Scott’s previously held stance. Scott didn’t just initially oppose taking part in the expansion — which the Supreme Court ruled to be optional last summer — he knowingly cited wildly inaccurate figures to inflate the program’s cost to the state by 2500 percent in an effort to discredit it. He eventually dropped his estimate for the expansion by $23 billion in the face of intense media scrutiny. The federal government will pay the lion’s share of funding for states that expand Medicaid, including fully funding expansions for the first three years.

Participating in the expansion will provide medical and financial security to about one million low-income Americans in Florida, a state that has one of the nation’s highest uninsurance rates. But some public health officials worry that Scott’s concurrent decision to privatize the state’s Medicaid program could leave poor Americans by the wayside. An initial pilot program for the privatization in five Florida counties was rife with collusive practices, dropped coverage, and profit-making at the expense of Floridians’ health — but Florida lawmakers claim that they have fixed the problems, citing “increased oversight and more stringent penalties, including fining providers up to $500,000 if they drop out.”

Scott’s decision comes after intense lobbying by Florida’s hospitals, who would benefit greatly from treating low-income Floridians with actual insurance as it would substantially lower their uncompensated care costs. “If Florida doesn’t expand Medicaid, we’re going to have the money taken out of one pocket, we just won’t get it put back in the other,” said Tommy Inzina, chief administrative officer at BayCare Health System.

But regardless of Scott’s motives, his actions could serve as a model for the 10 remaining GOP governors who have still not announced whether or not they will take part in Obamacare’s Medicaid expansion. To date, six other Republican governors — in Arizona, Michigan, New Mexico, North Dakota, Ohio, and Nevada — have decided to expand their Medicaid programs. Wisconsin’s Scott Walker recently announced his own alternative plan that, while better than nothing, will substantially limit the number of services and benefits that low-income Wisconsinites have access to.