The most direct consequence of states refusing to accept the Medicaid expansion is people suffering from avodiable death and/or suffering because they don’t have medical insurance. The problems are going beyond this as well:

While record numbers of Americans sign up for the larger Medicaid health insurance program for the poor, financial issues are emerging for medical care providers in the two dozen states that didn’t go along with the expansion under the Affordable Care Act. Reports out in the last week indicate the gap between those with health care coverage is widening between states that agreed to go along with the health law’s Medicaid expansion and those generally led by Republican legislatures and GOP governors that are balking at the expansion. The moves against expansion are “beginning to hurt hospitals in states that opted out,” a report last week from Fitch Ratings said. The U.S. Department of Health and Human services has said Medicaid enrollment in the 26 states and the District of Columbia that agreed to go along with and implemented the expansion by the end of May “rose by 17 percent, while states that have not expanded reported only a 3 percent increase,” HHS said in an enrollment update for the Medicaid program. “We expect providers in states that have chosen not to participate in expanded Medicaid eligibility to face increasing financial challenges in 2014 and beyond,” Fitch said in its July 16 report. “Nonprofit hospitals and healthcare systems in states that have expanded their Medicaid coverage under the Patient Protection and Affordable Care Act have begun to realize the benefit from increased insurance coverage.”

I once again turn things over to Brad DeLong:

This is the piece of the article that leaves me most annoyed because of the absence of context. Why have 20 states refused to take part in Medicaid expansion? It’s not because of how the Affordable Care Act was written. All states currently participate in Medicaid–it is a good deal for a state to do so. The ACA changed Medicaid. But John Roberts rewrote the law from his post on the Supreme Court to give states the option of (a) simply continuing with Medicaid-as-it-exists-in-2013 in addition to the options of (b) participating in Medicaid-as-it-exists-in-2014 and (c) dropping Medicaid entirely. When John Roberts rewrote the ACA from the bench, he did so very badly. The expansion of Medicaid meant that a great many people who used to show up at safety-net hospitals without any insurance at all will now be covered by Medicaid, so the rationale for the Disproportionate Share Payments to safety-net hospitals that treat the uninsured will go away, hence the ACA eliminates the no longer-needed DSP. But in states in which Medicaid isn’t expanded, the need for the DSP remains. When Roberts rewrote the law, did he rewrite the law so that the DSP remains for states that do not accept Medicaid expansion? No. Will safety-net hospitals in non-expanding states close as a result? Some of them, probably, without some other emergency fix. Did Roberts know what he was doing? Almost surely not. If you rewrite a law from the bench, shouldn’t you and your clerks first familiarize yourself with the law enough so that you know what you are doing? Next question!

Although the Medicaid portions of Sebelius used exceedingly unpersuasive reasoning to produce a horrible outcome, however, the states remain free to take the expansion. The fact that Republican-controlled ones generally aren’t tells you everything you need to know about the contemporary Republican Party.