States can opt out, but...

...they probably won't.

Republican governors and local representatives complain about “government run healthcare,” but if they don’t get with the program, they may have no healthcare.

According to new findings by the National Association of Public Hospitals and Health Systems (NAPH), by 2019, safety net hospitals’ uncompensated care costs will be $53 billion higher than originally estimated if states don’t opt into the voluntary expansion of the Medicaid program under Obamacare.

Safety net hospitals serve areas where, on average, 14.9 percent of the population is uninsured and 32.5 percent of the population relies on government-provided health coverage such as Medicaid. Current Medicaid reimbursements often fall short of the full cost of care, so programs such as federal DSH funding help make up the difference. Obamacare cuts DSH funding in half by 2019 in an effort to reduce national hospital payments — but only because the cuts to safety net hospitals were intended be offset by the vastly expanded pool of newly insured low-income Americans.

In hindsight making the expansion of Medicaid voluntary may not have been ideal, but making it mandatory also may have lead to the entire law being struck down. Because even in its current iteration, the Affordable Care Act survived by a razor-thin margin and ultimately relied on Chief Justice John Roberts having a last-minute change of heart.

With that said, I expect much of the opposition to the expansion of Medicaid will fade away after election season is over, and will almost entirely disappear in 2014 when the remainder of the law comes into effect.

This study, conducted by the National Association of Public Hospitals and Health Systems, suggests they simply won’t be able to afford not to. And perhaps more importantly, refusing to expand Medicaid will be very bad for business.

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