Radical right-wingers in a series of red states are punishing hundreds of thousands of low-income people by blocking efforts by Republican governors to expand Medicaid—state-run health care—by modifying Obamacare to include Republican ideas.

Last week, Tennessee Gov. Bill Haslam’s alternative plan to expand Medicaid to an estimated 250,000 uninsured adults died in a state Senate committee after opponents with deep ties to the Koch brothers won a 7-4 vote. Haslam, chair of the Republican Governors Association, included GOP proposals like creating health reimbursement accounts to help individuals pay for out-of-pocket expenses, premiums and co-pays. Tennessee’s Hospital Association, Business Roundtable and Medical Association all supported his reforms, yet senior GOP legislators fell under the libertarian extremists’ spell that the federal government could not be trusted with its funds or red tape.

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“We’re the third-worst state in the country for accepting federal dollars,” Andrew Ogles, Americans for Prosperity’s state director said during the debate. “It’s time for us to stop. Anytime we have a problem, instead of coming up with a Tennessee solution, we run to the federal government with our hands out. No more.”

Of course, the clamor for a state-based solution—a talking point repeatedly cited by Tea Partiers across the country who oppose Medicaid expansion—is no solution at all. It is a return to the status quo where thousands upon thousands lack reliable health care.

That dynamic could be seen in the anti-Obamacare crusade that last week also lead to the death of Wyoming’s Medicaid expansion bill, which was supported by Republican Gov. Matt Mead and would have helped more than 17,000 low-income residents. That bill’s demise also occurred in the early legislative process. Right-wing activists told lawmakers that many had won office opposing Obamacare. It didn’t matter that the bill’s sponsors created a “revenue-neutral proposal,” as Senate President Phil Nicholas said after its defeat, responding to critics who said it would lead to fiscal doomsday.

“While I respect different views, the fact is today we are left with working poor without coverage,” Gov. Mead said, after the naysayers blocked legislation, underscoring there are no ready state-based solutions to the problem of providing health care for the poor.

So far in 2015, Indiana—where Republican Gov. Mike Pence is eyeing a presidential run—has been the only red state to expand its Medicaid program under Obamacare, making it the 28th state to do so. But Pence added conditions that federal regulators grudgingly approved—allowing it to “to lock residents out of the program for six months if they fail to pay premiums,” according to Advisory.com’s summary. Still, 350,000 previously uninsured state residents will now have access to health care.

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Meanwhile, AFP has been threatening lawmakers in other states where Medicaid expansion is being considered. Take Montana, where Democratic Gov. Steve Bullock wants to help 70,000 residents. At grassroots meetings, AFP organizers have been threatening Republican legislators who refuse to sign no-expansion pledge cards. “Part of the reason we are doing this is because some legislators are not acting like adults in the Capitol,” Montana AFP Director Zach Lahn told the Great Falls Tribune, before absurdly adding that AFP was not engaged in electoral politics but public education.

In Utah, Gov. Gary Herbert wants to expand Medicaid to help 90,000 state residents. The Salt Lake Tribune reported there are competing GOP plans, where the sticking point is how many people will get covered. Tennessee, Wyoming and Utah are the three states that were being most closely watched in 2015 for possible Medicaid expansion. There are similar debates in other red states, such as Idaho and Alaska, but advocates are not optimistic.

Meanwhile, there are other worries on the Medicaid front. In other states, such as Ohio, there are GOP-led efforts to possibly roll back Medicaid expansion or impose conditions that would take away coverage from large numbers of people. Last Friday, Ohio sent letters to 107,000 Medicaid recipients telling them they could lose their coverage by Feb. 28 unless they verified their incomes.

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The Columbus Dispatch reported that 500,000 Ohians will receive similar notices in the next six months. The state has 2.9 million Medicaid recipients, including 450,000 who were added last year when Republican Gov. John Kasich expanded the program. He’s been criticized by the same cadre of right-wingers blocking expansion in other states.

In Arkansas, Republican legislators decided to fund their expansion for another two years, which helps recipients buy private health plans. Meanwhile, in Illinois, the newly elected Republican governor is said to be eyeing a Medicaid roll-back, citing higher than expected near-term costs.

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While it is not a surprise that the Republican war on Obamacare continues, it is new to see a handful of Republican governors push for Medicaid expansion while the GOP’s Koch wing is essentially intimidating state lawmakers into voting no. That suggests there might be a growing split in the party as 2016 looms on the horizon and presidential candidates acknowledge inequality is an issue.

In the short run, however, those political currents do nothing for poor people who can’t get the health care they need, or might lose recently acquired coverage, such as in Ohio, should the state mistakenly send their renewal paperwork to wrong addresses.