A hearing this week before the Senate Subcommittee on Primary Health and Aging shows what happens when Republican obstruction of the Affordable Care Act moves from the ridiculous to the sublime. When Senator Richard Burr (R-NC) tried to demonize the single payer Canadian system by asking Dr. Danielle Martin how many people die on Canadian waiting lists each year, the vice president of Medical Affairs at Toronto's Women's College Hospital rightly responded, "I don't, sir, but I know that there are 45,000 in America who die waiting because they don't have insurance at all." No doubt hoping to muffle the guffaws echoing from Halifax to Nanaimo (and from much of America, for that matter), Senator Burr turned to the GOP's tried and untrue alternative to any health care reform plan:

"The American system has access to healthcare for everybody; it's called the emergency room."

But just because President Bush, Tom Delay (R-TX, Mitt McConnell (R-KY), Paul Broun (R-GA), Mitt Romney (R-MA), Phil Bryant (R-MI) and almost every major Republican figure has uttered some variant of the GOP ER plan ("people have access to health care in America--after all, you just go to an emergency room") doesn't make it true. And now, Georgia Governor Nathan Deal wants to restrict emergency room access for the uninsured for the simple reason he doesn't want his state to pay for it.
As the Atlanta Journal Constitution recently reported:

Gov. Nathan Deal has often called on Congress to reconsider the Affordable Care Act. But on Monday evening, he pushed his former Washington colleagues to revisit a separate health care law that fewer politicians openly critique.
The Emergency Medical Treatment and Labor Act is a 1986 law that requires hospitals to provide emergency health care treatment to anyone who needs it, regardless of citizenship or their ability to pay. It's provided life-saving care to countless people, but it's also strained hospital resources and turned emergency rooms into the first stop, instead of a last resort, for some.
"If they really want to get serious about lowering the cost of health care in this country, they would revisit another federal statute that has been there for a long time," Deal told a crowd of dozens at a University of Georgia political science alumni gathering. "It came as a result of bad facts, and we have a saying that bad facts make bad law."

But with the Affordable Care Act, the federal government did provide a solution: expanding Medicaid to millions of low-income, uninsured Americans in states like Georgia. But when Nathan Deal, like many other Republican Governors said no, he not only needlessly created a "coverage gap" leaving an estimated 530,000 Georgians without health insurance. Governor Deal also put Georgia's hospitals and their patients at risk.
Four rural hospitals have already announced their looming closures. Two of Georgia large metropolitan hospitals (Savannah Memorial and Grady Memorial in Atlanta) will face major financial shortfalls. And it's all because Nathan Deal said no to $33 billion in federal Medicaid funding over the next decade.
Here's why.
But as the federal government significantly reduces funding on Disproportionate Share Hospital (DSH) payments for the care of the uninsured, states like Georgia which turned down Obamacare's Medicaid dollars will be on the hook to make up the difference. For Grady Memorial Hospital, the largest in the metro Atlanta area, what could have been an annual boon of $60 million and coverage for 27,000 uninsured patients instead will be a $45 million loss. Georgia taxpayers will have to pay more even as hospitals likely cut services. Meanwhile, three cash-strapped rural hospitals have already closed their doors. Another 15 may follow suit in 2014. All because a Republican Governor said "no" to free money from Washington, DC.
And the funding is virtually free to the states. The federal government will pay for 100 percent of the cost of the Medicaid expansion until 2017 and 90 percent after that. The loss to rejectionist red state coffers, the Commonwealth Fund found, is staggering. As USA Today summed it up:

By 2022, Texas could lose $9.2 billion by not expanding Medicaid as allowed under the Affordable Care Act, while Florida could lose $5 billion over that period, the study conducted by The Commonwealth Fund shows...Also during that period, the study showed, Georgia could lose $2.9 billion, while Virginia could lose $2.8 billion.
"There are no states where the taxpayers would actually gain by not expanding Medicaid," said Sherry Glied, lead author on the study. "Nobody wins."

The billions the "opt-out" states will have to come up with in future years will be more than offset by their extra costs to compensate hospitals and other providers for the care of the uninsured. As Ezra Klein and Evan Soltas summed up an analysis by the RAND Corporation of 14 Medicaid rejecting states last year:

It finds that the result will be they get $8.4 billion less in federal funding, have to spend an extra $1 billion in uncompensated care, and end up with about 3.6 million fewer insured residents.
So then, the math works out like this: States rejecting the expansion will spend much more, get much, much less, and leave millions of their residents uninsured. That's a lot of self-inflicted pain to make a political point.

That goes in spades for Nathan Deal. Rather than take President Obama's money to run the Peach State's hospitals, Nathan Deal would prefer to leave hundreds of thousands uninsured and put an end to the only health care plan Republicans have consistently supported. (Unsurprisingly, he wants to avoid accountability for his decision by shifting responsibility for the Medicaid rejection to the Georgia state legislature.) In Deal's ideal Georgia, you couldn't just go to the emergency room.