ATLANTA - As more Republicans give in to President Obama's health-care overhaul, an opposition bloc remains across the South, including from governors who lead some of the nation's poorest and unhealthiest states.
"Not in South Carolina," Gov. Nikki Haley declared at the recent Conservative Political Action Conference. "We will not expand Medicaid on President Obama's watch. We will not expand Medicaid ever."
Widening Medicaid insurance rolls, a joint federal-state program for low-income Americans, is an anchor of the law Obama signed in 2010. But states get to decide whether to take the deal, and from Virginia to Texas - a region encompassing the old Confederacy and Civil War border states - Florida's Rick Scott is the only Republican governor to endorse expansion, and he faces opposition from his GOP colleagues in the legislature. Tennessee's Bill Haslam, the Deep South's last governor to take a side, added his name to the opposition on Wednesday.
Haley offers the common explanation, saying expansion will "bust our budgets." But the policy reality is more complicated. The hospital industry and other advocacy groups continue to tell GOP governors that expansion would be a good arrangement, and there are signs that some Republicans are trying to find ways to expand insurance coverage under the law.
Haslam told Tennessee lawmakers that he'd rather use any new money to subsidize private insurance. That's actually the approach of another anchor of Obama's law: insurance exchanges where Americans can buy private policies with premium subsidies from taxpayers.
Yet for now, governors' rejection of Medicaid expansion will leave large swaths of Americans without coverage because they make too much money to qualify for Medicaid as it exists but not enough to get the subsidies to buy insurance in the exchanges. Many public health studies show that the same population suffers from higher-than-average rates of obesity, smoking and diabetes - variables that yield bad health outcomes and expensive hospital care.
"Many of the citizens who would benefit the most from this live in the reddest of states with the most intense opposition," said Drew Altman, president of the nonpartisan Kaiser Family Foundation.
So why are these states holding out? The short-term calculus seems heavily influenced by politics.
Haley, Haslam, Nathan Deal of Georgia and Robert Bentley of Alabama face re-election next year. Mississippi Gov. Phil Bryant is up for re-election in 2015. Louisiana Gov. Bobby Jindal is term-limited at home but may seek the presidency in 2016. While they all govern GOP-leaning states, they still must safeguard their support among Republican voters who dislike large-scale federal initiatives in general and distrust Obama in particular. Florida's Scott, the South's GOP exception on expansion, faces a different dynamic. He won just 49 percent of the vote in 2010 and must face an electorate that twice supported Obama.
A South Carolina legislator put it bluntly earlier this year. State Rep. Kris Crawford told a business journal that he supports expansion, but said electoral math is the trump card. "It is good politics to oppose the black guy in the White House right now, especially for the Republican Party," he said.
Whit Ayers, a leading Republican pollster, was more measured, but offered the same bottom line. "This law remains toxic among Republican primary voters," he told The Associated Press.
At the Tennessee Hospital Association, President Craig Becker has spent months trying to break through that barrier as he travels to civic and business groups across Tennessee. "It's really hard for some of them to separate something that has the name 'Obamacare' on it from what's going to be best for the state," he said, explaining that personality driven politics are easier to understand than the complicated way that the U.S. pays for health care.