While the Patient Protection and Affordable Care Act is garnering plenty of criticism as it enters its third open enrollment period, there is at least one provision of the landmark health law that many of the law's critics may soon be forced to embrace: the federally-funded expansion of Medicaid.

Montana became the 30th state to take part in the expansion on Monday, when the Obama administration approved the state's request for the additional federal funds, which will guarantee coverage for those living up to 133 percent of the federal poverty level.

Almost entirely financed by the federal government –– at least in the near future –– the expansion has extended coverage to millions of low-income Americans while avoiding many of the problems that have bedeviled the private insurance exchanges.

Even the governors who are holding out are getting pressure from members of their own party who have heard from cash-strapped hospitals and constituents struggling to pay medical bills.

Perhaps the most important example is Texas, the only state with an uninsured rate north of 20 percent. Although Gov. Greg Abbott hasn't budged an inch from his categorical opposition to any Obamacare-affiliated programs, a number of local leaders, including conservatives, say that if the feds are going to be spending the money, the least the state could do is try to get its share.

Judge Ed Emmett, the Republican chief executive of Harris County, where Houston is located, has been begging for the money since the beginning. But his calls in 2013 to accept the money on behalf of Texas taxpayers who were paying into the federal coffers largely fell on deaf ears.

But now that local officials are seeing the economic effect of the expansion in other states historically burdened by high uninsured rates, such as Arkansas and Kentucky, the calls for Texas to drop its fight against the feds are growing louder. George Masi, the head of a Harris Health System, a community-owned health care system in Harris County, told NPR that he has recently had to lay off 100 workers, a decision that may have been averted with more Medicaid funding.

"What is even more profound is that money is going to other states that expanded Medicaid, like New York, California, Connecticut," he said. "And so the taxpayer of Texas is being penalized, if you will, for not taking advantage of that option."

Ken Janda, who runs Community Health Choice, a nonprofit insurer, floated an argument in favor of Medicaid expansion that some Republicans will no doubt find hard to resist.

"If Texas expanded Medicaid, we would be able to look at reducing local property taxes across the board in all counties, or use those dollars for something besides health care," he said.

Instant Insights /

States facing increased pressure to expand Medicaid

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