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The health care reform law calls for a big expansion of Medicaid, the federal healthcare program for the poor. But last year’s Supreme Court made that expansion optional. And some of the biggest states, with the most poor people, are opting out. 

So far, 23 states and the District of Columbia have agreed to expand Medicaid, six are undecided, and 21 have said no. Among them: Texas, which is where 47-year-old Ricardo Rios lives. He would qualify for Medicaid, under the health care law’s expansion plan if Texas hadn’t opted out. He’s praying the state’s leaders change their minds.

“We just have to pray that everything will go well and it’ll change," he says.

If things don’t change, Rios will continue to struggle with being poor and uninsured. He’s supposed to take medication for high blood pressure and insulin for diabetes. Sometimes he doesn’t  have enough money to pay for his medicine, so he skips it. The lack of insulin leaves him weak, and drowsy.

“I just take a nap and hope I can wake back up again," he says. "That I don’t end up passing away.”

There are a lot of people in Ricardo Rios’s shoes. In fact, about two thirds of the low-income uninsured who would qualify for Medicaid under the healthcare law, live in states that will not expand it.

Robin Rudowitz, a healthcare analyst at the Kaiser Family Foundation, says there will be a huge coverage gap. She says the uninsured will continue to face, “High out of pocket costs as well as really going without care or delaying care that they need.”

Until they get so sick they end up in the emergency room -- in many cases, unable to pay. The hospitals will have to treat them for free. They may ask for more state aid. The federal government subsidizes some free care. But, under health care reform, those subsidies shrink on the theory that more people will be insured.

Stephen Zuckerman, who co-directs the Health Policy Center at the Urban Institute, says hospitals in states that don’t expand Medicaid will come under increasing strain. 

“Ultimately, that could lead these hospitals to restrict care to these uninsured populations," he explains. "So, it could be a problem, three, four years out.”

And Zuckerman says those hospitals will start pressuring their states to reconsider and expand Medicaid. Federal officials say states are free to change their minds anytime. 

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