The push to shutter the government instead of implementing Obamacare is a macrocosm of a fight Republicans have already won: condemning millions of extremely poor residents of their states to the uncertainty that comes from no health care coverage.

A stunning report from The New York Times indicates that, even after the Affordable Care Act goes into full effect on January 1, millions of Americans will still lack health coverage because they are too poor to qualify for subsidized plans and live in states that refuse to expand Medicaid coverage. It's another dimension to the political struggle over Obamacare that's crippled the government — but one with an immediately harmful effect on actual Americans.

The roll-out of President Obama's health care program was meant to accomplish several things. Those with existing employer coverage wouldn't be affected. Those without employer coverage could sign up for an insurance plan under one of the state-based insurance exchanges that pooled various options, and at certain income levels, those plans would be subsidized. For those whose incomes were below a certain level, the federal Medicaid program would be expanded to cover them. Each of these plans has seen hiccups, of course. A few employers have rolled back coverage for their employees, offering ammunition to the president's opponents. The website offering enrollment in the exchanges has been hammered with traffic.

And then there's Medicaid. From the Times' report, with emphasis added.

A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help

The ostensible hang-up for the states that have chosen not to participate in the expansion is this: "The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years." "Even supporters of the health law," the report later continues, "say that eventually covering 10 percent of that cost would have been onerous for a predominantly rural state with a modest tax base." The one slightly-bright side for the millions of working and unemployed poor excluded from the program is that they will not be subjected to the financial penalty that applies to others who lack insurance. Just the financial penalties that result from having to seek medical treatment without having any costs offset by an insurer.

As the Times points out, there is also significant overlap between the states that have rejected the expansion and other demographics indicators. Those states are much more likely to have high populations of people of color and more people living in poverty.

To give a sense of how demographic factors overlap with the rejection of the expansion, we created a series of maps outlining some of the data characteristics of those states that won't expand coverage. (The Times also has a more limited interactive map that's worth a look.) In general on the maps below, the darker the color represents a larger number.

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States not expanding Medicaid


There is, as the Times suggests, significant overlap between poverty, lack of insurance, and race — inescapably so. It quotes Dr. Aaron Shipley, a physician who works in Mississippi. "If you look at the history of Mississippi, politicians have used race to oppose minimum wage, Head Start, all these social programs. It’s a tactic that appeals to people who would rather suffer themselves than see a black person benefit."

Others contest that description of the state's politics, unsurprisingly. But the implication is obvious: states unwilling to pay ten cents on the dollar to ensure that their populations aren't subject to massive medical bills are clearly comfortable with shifting that economic burden onto the extremely poor.

It's impossible not to consider this issue in light of the current government shutdown, prompted explicitly by the desire to halt all three components of the president's healthcare plan. On Wednesday, Republican Rep. Marlin Stutzman gave the Washington Examiner a now-famous quote about the need for his party to walk away from the shutdown with some sort of victory. "We’re not going to be disrespected. We have to get something out of this. And I don’t know what that even is."

Stutzman represents Indiana. In 2009, 14.2 percent of the state lacked insurance; in 2011, 45 percent of the black population and one-fifth of the whole state lived in poverty. Indiana is not expanding Medicaid coverage for its residents. They are not getting something out of the shutdown, to be sure. But the state's poor are also not getting something out of Obamacare. That is being disrespected.

Photo: Medical assistant Angelica Colmenero takes the blood pressure of Jose Martinez at the 4th Street Clinic Wednesday, Sept. 25, 2013, in Salt Lake City. Martinez already has Medicaid coverage, though Utah isn't expanding. (AP)