The nation's hospitals and the poor in Texarkana have a common problem

Texarkana's unique position of existing in two states that have taken different positions on Medicaid expansion neatly illustrates the torturously fractured implementation of the Affordable Care Act, according to the New York Times.

Texarkana's courthouse literally straddles the state border, and so do its residents. There are people who live in the Texas side--in a homeless shelter--but work on the Arkansas side. They thus have no way, for example, to pay a $600 bill for cursory dental care provided at a hospital emergency room. There are also people who live in a tent on the Texas side but get their meals at the Salvation Army on the Arkansas side.

Despite their mobility, the poor who dwell on the western end of Texarkana cannot bring themselves to make a simple move to improve their lives. Many are either in denial due to fear, or are wholly ignorant of the existing opportunities, according to the article.

The same can be said of the states that continue to refuse to expand Medicaid. Their leaders are engaged in behaviors as contradictory and maddening as those in Texarkana.

There's North Carolina and Pennsylvania to start, the News & Observer reports. The U.S. Department of Health and Human Services recently turned down proposals by both states to tax Medicaid managed care plans that provide behavioral care services in order to draw down more matching federal dollars.

As a result, the Tar Heel State currently faces a $60 million shortfall in its Medicaid program, and the Miami Herald reports is now considering classy maneuvers to fill the gap, such as cutting 15,000 aged, blind and disabled from the rolls.

The feds said that in order for such a tax to pass muster, it would have to be levied on all health plans participating in the Medicaid program. It should have simply pointed out that there is billions of dollars for the taking if those states simply expanded Medicaid eligibility--an act nearly as simple to perform as walking a few yards across a border.

Meanwhile, the state government in Virginia is on the verge of a shutdown over Medicaid expansion.

Gov. Terry McAuliffe, a Democrat who won election last November by campaigning on the promise of expanding Medicaid to some 400,000 Virginians, appeared to have had enough support in the statehouse to push it through. But according to Business Insider, the state GOP has persuaded a Democratic senator to resign in exchange for an appointment to a tobacco commission and confirmation of his daughter to a judgeship. His resignation would revert control of the Senate back to the Republicans, who have indicated they won't pass a fiscal 2015 budget that includes expansion. On July 1, the government will shut down without a budget in place.

"Republicans I've talked to are chortling," Larry Sabato, founder and director of the University of Virginia Center for Politics, told Business Insider. "They think it's one of the cleverest things they've done. And, yet, do you think Democrats would not have done the same thing if they had the opportunity? And of course they would have."

Democratic politicians might have done the same thing, but in this instance it would have been in the service of providing healthcare access to poor people. Sabato makes an apples to rotten apples comparison.

So, another state that could have easily accepted funding to expand its safety net appears willing to veer toward a meltdown instead.

Again, hospitals seem to be woefully absent from the debate. That may be part of the geography in the case of Texarkana, as all of the acute care facilities are on the Texas side of town, making a campaign to enroll its low-income patients in Medicaid moot.

However, given the loosening of campaign financing laws in recent years, hospitals and state hospital lobbying could have easily used their resources--in the form of targeted contributions and advertising campaigns--to pressure lawmakers to change their minds on Medicaid expansion.

But much like the tent dwellers in Texarkana, they've been frustratingly reluctant to stand up for themselves. And as the evidence continues to roll in that hospitals in states that refused to expand Medicaid are seeing their bottom lines damaged, it is becoming clearer that like the poor on the west side of Texarkana, they have no one to blame but themselves. - Ron (@FierceHealth)

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