Left holding the bag, of course, will be healthcare providers, especially hospitals. They get the worst of both ends. They don't reap the benefit of seeing more insured patients, and their reimbursements for Medicare and Medicaid are being cut through the federal budget process and sequestration mandates.
"It's a difficult financial model," says John Hawkins, senior vice president for government relations at the Texas Hospital Association. "Trying to balance those cuts without being able to expand coverage is going to be difficult going forward."
In all likelihood, dwindling funding could mean that some smaller or financially strained hospitals will close. "For rural hospitals that is probably more the reality. In other areas you will see hospitals limit services which can be equally as challenging for their communities," Hawkins says.
"You are going to have worse health outcomes, particularly in areas where facilities have to limit services. Folks will have to drive farther. Your workforce isn't going to be as productive because of lack of coverage. The bigger impact will be poorer health outcomes and less-productive state."
It's not just the usual public advocacy groups who are calling for expanding the Medicaid rolls. Leading business groups in Texas have called for some sort of action. Hawkins says there has been a "continued drum beat" for expanding the rolls from a wide swath of special interest groups that recognize what is at stake.