Something terrible has happened to pregnant women in Texas: their mortality rate has doubled in recent years, and is now comparable to rates in places like Russia or Ukraine. Although researchers into this disaster are careful to say that it can’t be attributed to any one cause, the death surge does coincide with the state’s defunding of Planned Parenthood, which led to the closing of many clinics. And all of this should be seen against the general background of Texas policy, which is extremely hostile toward anything that helps low-income residents.

There’s an important civics lesson here. While many people are focused on national politics, with reason — one sociopath in the White House can ruin your whole day — many crucial decisions are taken at the state and local levels. If the people we elect to these offices are irresponsible, cruel, or both, they can do a lot of damage.

This is especially true when it comes to health care. Even before the Affordable Care Act went into effect, there was wide variation in state policies, especially toward the poor and near-poor. Medicaid has always been a joint federal-state program, in which states have considerable leeway about whom to cover. States with consistently conservative governments generally offered benefits to as few people as the law allowed, sometimes only to adults with children in truly dire poverty. States with more liberal governments extended benefits much more widely. These policy differences were one main reason for a huge divergence in the percentage of the population without insurance, with Texas consistently coming in first in that dismal ranking.

And the gaps have only grown wider since Obamacare went into effect, for two reasons. First, the Supreme Court made the federally-funded expansion of Medicaid, a crucial part of the reform, optional at the state level. This should be a no-brainer: If Washington is willing to provide health insurance to many of your state’s residents — and in so doing pump dollars into your state’s economy — why wouldn’t you say yes? But 19 states, Texas among them, are still refusing free money, denying health care to millions.