From the beginning, the defining irony of the never-ending debate over Obamacare is this: health care is worst in those states where Republicans poll best. The map of the states with the worst health care systems largely mirrors GOP strongholds in the Electoral College. Red state residents are generally the unhealthiest and more likely than their blue state cousins to be uninsured. Nevertheless, the New York Times reminded readers on Friday, Republican governors and legislators are rejecting the ACA's expansion of Medicaid that could bring health insurance to millions more of their residents.

As Robert Pear reported, "The refusal by about half the states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance under President Obama's health care law even as many others with higher incomes receive federal subsidies to buy insurance." The cruel ironies don't end there:

Starting next month, the administration and its allies will conduct a nationwide campaign encouraging Americans to take advantage of new high-quality affordable insurance options. But those options will be unavailable to some of the neediest people in states like Texas, Florida, Kansas, Alabama, Louisiana, Mississippi and Georgia, which are refusing to expand Medicaid.
More than half of all people without health insurance live in states that are not planning to expand Medicaid.

The impact of that rejection is staggering. The Urban Institute estimates that 5.7 million uninsured adults with incomes below the poverty level would gain coverage except that they live in states that are not expanding Medicaid. That includes almost 1 million Floridians and another 1.5 million in Texas, people who will be forced to go without health insurance despite the fact that Washington would pick up the bill for their states through 2017 and 90 percent of it after that. Despite leading a state with the 46th ranked health care system and 30 percent of those ages 18 to 64 uninsured, Governor Rick Perry declared the Lone Star State would have nothing to do with Obamacare's expansion of Medicaid. As Politico recounted the scene in April:

"Texas will not be held hostage to the Obama administration's attempt to force us into this fool's errand," he said, flanked by Republican Sens. John Cornyn and Ted Cruz and Reps. Joe Barton and Michael Burgess.

Of course, the real hostages are the millions of uninsured in states governed by Republicans. As Roy S. Mitchell, the executive director of the Mississippi Health Advocacy Program lamented, ""there's going to be a huge void" as many uninsured poor people find that they are not eligible for Medicaid or insurance subsidies. "There will be an outcry."
Especially when those lower-income red staters find out about the final, cruel irony of their Republican leaders' rejection of the Obamacare Medicaid expansion. In keeping with the persistent dynamic of red state socialism, blue state taxpayers would have helped pay for it.
(For more background, see "Health Care is Worst Where Republicans Poll Best.")