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As a federal health care law is implemented around the country, states face an important decision: whether to expand Medicaid, the insurance program for the poor. The law calls for an expansion, and some of the law's more vocal Republican opponents - including the governors of Arizona, Ohio and New Jersey - say they intend to follow through.

But that hasn't swayed Governor Rick Perry of Texas, whose state has the highest rate of uninsured in the country. He says Texas won't expand Medicaid. He and his supporters argue, among other things, that they don't believe Congress will pay its share for an expansion, leaving a state like Texas in a financial bind. We're going to pay a visit now to a place where Medicaid has played a big role: the Rio Grande Valley and blue-collar border towns like Brownsville, Texas. Sarah Varney reports.

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SARAH VARNEY, BYLINE: A warm, tropical breeze signals the start of a spring morning in Brownsville.

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VARNEY: Noisy black birds called urracas blanket the tops of palm trees. The roads are lined with trucks headed to the local shipyard. At the southernmost tip of Texas, in the Rio Grande Valley - closer to Mexico than the state capital of Austin - Brownsville is awake and on the move, and, according to Mike Siefert, a former Catholic priest and longtime resident, largely forgotten.

MIKE SIEFERT: I think one of the huge frustrations about living in the Rio Grande Valley, even though we're about one-and-a-half-million people and the poorest region of a very wealthy state, is that we are totally ignored.

VARNEY: The Rio Grande Valley has a load of troubles: high unemployment, low-paying jobs, warring Mexican cartels, a meager tax base and legions of people without health insurance. While many of those woes seem incurable, expanding Medicaid to the region's uninsured is to Paula Gomez - who runs several local health clinics - a no-brainer.

PAULA GOMEZ: I think if we're not ready, if Texas doesn't buy in in the next three months, shame on us, because that means we're - I'm going to say it. I think we're derelict in our responsibilities to our residents in this great state.

VARNEY: Gomez pulls up on her computer a list of some 4,000 uninsured patients who would be eligible, based on their income, for Medicaid, should Texas opt in as part of the Affordable Care Act. Gomez says for safety net clinics like hers, those added Medicaid dollars would go a long way.

GOMEZ: You're talking huge bucks. It's over a million dollars that we would be able to then turn around and expand and give more services to.

VARNEY: But Governor Perry says Texas can ill-afford to expand Medicaid, and he doesn't trust that Congress will pay its promised share. He held a press conference last month reaffirming his position.

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GOVERNOR RICK PERRY: Seems to me an appropriate April's Fools Day event to - makes it perfect to discuss something as foolish as Medicaid expansion, and to remind everyone that Texas will not be held hostage by the Obama administration's attempt to force us into this fool's errand of adding more than a million Texans to a broken system.

VARNEY: A spokesperson says Governor Perry's position has not changed, and maintains that the expansion is fiscally irresponsible. For now, those uninsured patients in the Rio Grande Valley pay what they can for basic medical care. But specialty care - to follow up on a lump in the breast, for example - is almost always out of reach without some type of insurance, including Medicaid, says Dr. Henry Imperial, the clinic's medical director.

HENRY IMPERIAL: Once you diagnose a cancer, then what? How are you going to give me chemotherapy or surgery or radiation therapy? It goes out of our hand.

VARNEY: Imperial says he often plies fellow doctors with beer to see his patients.

IMPERIAL: Oh, Henry, it's one of your patients again? What is it this time? It's just tough. You know, I cannot do appendectomy. I cannot operate on gall bladders. I need a surgeon.

VARNEY: Hospitals in Texas end up with millions in unpaid bills, and the counties, by state law, have to provide basic medical care to destitute residents. That's led a number of counties in the Rio Grande Valley and elsewhere in Texas to pass resolutions supporting the Medicaid expansion. For local Republicans, that mild act of defiance against a powerful governor - who is opposed to every provision in the federal health law - can seem like political suicide. And it's not something they're eager to draw attention to. At the old Cameron County Courthouse in Brownsville, the county's top elected official - Carlos Cascos, a Republican - is deferential to Governor Perry. But he says the amount of money that would come into the county is a big number.

CARLOS CASCOS: It's contrary to what the leadership in Austin is recommending, but we thought it was important enough to take a position just to show the governor and the administration that, you know, there is support out there from the local municipalities, the local county governments and other officials.

VARNEY: Under the health law, the federal government would pay the entire cost of the expansion for the first three years, and 90 percent in subsequent years. By one estimate from the Center for Public Policy Priorities, Cameron County would see nearly $200 million from the Medicaid expansion in the first few years. Other urban counties would see much more.

STATE REPRESENTATIVE EDDIE LUCIO III: We have to not only speak loudly, but justify what we're doing and why we need these investment dollars in South Texas, or really throughout our state.

VARNEY: State Representative Eddie Lucio III is a Democrat from Brownsville. He faces daunting odds in trying to persuade the conservative Republicans who control the legislature to buck Governor Perry and approve a bill to expand Medicaid in Texas. Lucio says he's not sure what effect, if any, the resolutions by county officials - including Republicans like Carlos Cascos - are having.

LUCIO: I don't know what the play is. I don't know if he's hanging on, meaning the governor, to the very end.

VARNEY: There is ample pessimism here in Brownsville that lawmakers 350 miles away in Austin will ever understand life in the Valley.

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VARNEY: Back at Paula Gomez's clinic in the waiting room at the Brownsville Community Health Center, Mark Buitron, age 22, is not amused by the antics on a Spanish morning television show. Buitron has model good looks and wears his green varsity letter jacket. He's got the flu, he thinks. He's sweating and looks miserable.

MARK BUITRON: I was feeling ill today, so I couldn't go to work.

VARNEY: Buitron works 44 hours a week at the port of Brownsville tearing apart old cruise ships with no health insurance and no sick pay. His yearly income is less than $15,000. Buitron tells me he's been to the hospital once and received an $11,000 bill that he's never been able to pay. He's exactly the type of person the Medicaid expansion was meant to target: working adults who can't afford private insurance.

BUITRON: If I get sick in the future, I mean, how much are they going to charge me then?

VARNEY: Buitron leans back into his chair, stuffs his hands into his pockets and waits for his name to be called. For today's visit, he'll pay $25 in cash. Paul Gomez says the clinic often has to send patients with serious illnesses to the emergency room, knowing they'll get bills they can't pay.

GOMEZ: I can blame Perry all day long, but you know what? He's just one man. I think we've got a whole mess of other people that should be pushing, and he's not God in this state. He's just a governor.

VARNEY: There is no hard deadline for when Texas or any other state has to sign up for the Medicaid expansion. Gomez says she still remembers fighting the state to get potable water in the Rio Grande Valley, and she'll patiently fight this war, too. For NPR News, I'm Sarah Varney.

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GREENE: Sarah Varney is a reporter with Kaiser Health News, a nonprofit news service. Now, also on the program this morning, we're following the story of a massive tornado in Oklahoma that killed dozens of people. We'll be bringing you the latest throughout the program here on MORNING EDITION.

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