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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For more than a year, Texas lawmakers have been on a crusade against Planned Parenthood that has resulted in deep cuts to family planning services that thousands of women rely on. But, particularly after the state’s health department projected a sharp rise in unintended births as a direct result of the budget cuts, Texas Republicans are finally starting to regret that move. In an attempt to appease the voters who have attacked them for undermining low-income women’s preventative health resources, lawmakers on both sides of the aisle are now quietly working to restore the family planning funding they slashed.

As the Texas Tribune reports, the Democrats and Republicans in the state have struck an uneasy balance. Democrats have promised to stop fighting to restore state funding to Planned Parenthood, while Republicans have pledged to stop imposing additional barriers to women’s health care access:

“The major difference is we’re not fighting about it, we’re just doing what’s right for women and the state,” state Rep. Sarah Davis, R-West University Place, said last month at a Texas Tribune symposium on health care.

There has not been a drawn-out public debate on abortion or women’s health in either chamber this legislative session. None of the 24 abortion-related bills filed have reached the House or Senate floor. And Davis, the only Republican member of the House Women’s Health Caucus, brokered a bipartisan “grand bargain,” as lawmakers refer to it, to prevent amendments to the House budget bill that could have jeopardized an agreement to restore women’s health dollars.

For some Republicans, this bargain hinged on the ballot box: Davis said several of her colleagues faced blistering attacks after last session’s family planning cuts — an effort, in part, to drive Planned Parenthood out of business — shuttered clinics in their districts that were not affiliated with abortion providers.

Davis told the Texas Tribune that she is committed to providing adequate resources for family planning services for low-income women, and the best way to get that done is to “remove emotion” from the legislative process. According to Davis, the recent arguments about abortion and Planned Parenthood that fueled the legislature’s decision to slash those resources “did not advance the ball,” but rather “threw family planning into a tailspin.”

She’s right. Since the state cut its family planning budget by two-thirds, 53 family planning clinics have been forced to close their doors and an estimated 144,000 fewer women have received preventative health care. So now, in the state’s tentative 2014-15 budget, lawmakers are considering devoting even more money for women’s health services than the state was allocating to that area before the 2011 budget cuts.

But, in order to get Republicans on board, that funding is still being strictly designated to clinics that don’t provide abortion services. Texas legislators may be coming around on some aspects of women’s health, but fights over abortion continue to simmer under the surface. Gov. Rick Perry (R) — who has maintained that outlawing all abortion is his ultimate “goal” — has thrown his weight behind a 20-week abortion ban, and lawmakers are considering a measure that could force some abortion clinics in the state to close. Although lawmakers are finally realizing that low-income women have the right to accessible birth control and family planning counseling, they’re not concerned about those same women’s access to affordable abortion care.

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.