It's even worse political malpractice than is obvious. Those States opting out are going to subsidize via Federal Taxes the States that expanded medicaid!On the upside, that's more money left over for the states that do participate.
I am confident that people will be so outraged when the Democrats explain how much cash they are foregoing for the sake of ideology that even the most reactionary and ignorant Governors, Bryant in Mississippi for example, will be forced to expand if they have any hope of being re-elected. The Hospitals and Physicians are up in arms about this Republican lunacy. You won't see any reduction in Emergency Room use in those States Opting out, and it's a huge hit to those States' respective economies. I'll give them 6 months before they change their minds. If they don't, turning down all that money will be a huge campaign issue in the mid-term election.