One of the complexities of the Affordable Care Act weighing on states is the decision whether to participate in the ACA’s expansion of Medicaid coverage, after the Supreme Court last summer ruled that states may opt out of that aspect of President Obama’s signature healthcare reform law. Since then, state-level political leaders and medical associations have been considering their options.

In Texas, two of the largest medical groups, the Texas Medical Association and the Texas Hospital Association, have come out in favor of expanding Medicaid in the state. They’re finding little support from Republicans in the state government, including Gov. Rick Perry, who has promised to veto any bill that includes the expansion.

Here’s how the issue is playing out in the Lone Star State:

The argument: TMA and THA both favor the extension of Medicaid coverage for low-income adults, but only with the addition of cost-containment reforms. “The most viable path is to try to work with [the federal government] to create a reformed program that does meet the needs of Texas better,” THA’s senior vice president of government relations, John Hawkins, told The Texas Tribune. The associations are pushing for bipartisan reforms—and asking for flexibility from both parties.

The data: A recent report on the topic [PDF], written by nonpartisan public policy consultant Billy Hamilton, notes that the state’s investment of $15 billion will bring $100 billion in funds from the federal government—a total that could increase Medicaid coverage for 2 million Texans. “Criticism that Texas cannot afford an expansion ignores the fact that Texas state and local governments and hospitals already spend enough on adult health care to more than cover the $15 billion in state match necessary for the 10-year period,” Hamilton claims in his study.

What legislators think: While associations are pushing for the expansion, Texas lawmakers are largely moving in the other direction. One state senator, Republican Bob Deuell, argues that a block grant from the federal government that would allow for a state-built Medicaid program would be a better option. “I don’t think [the trade associations are] looking at the long-term, broader picture that I, as a legislator, am looking at,” he told the Tribune.

A potential workaround may come in the form of a constitutional amendment decided by voters, an idea some Texas Democrats are pushing.

Correction: An earlier version of this piece implied that Hamilton’s report was affiliated with the associations. Also, an earlier headline on the piece used the phrase “Medicaid expansion” when “Medicaid coverage expansion” was more accurate. In both cases, we regret the error.

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