It's health care brinksmanship, with hundreds of billions of dollars and the well-being of millions of people at stake.
President Barack Obama's health care law expands Medicaid, the federal-state health program for low-income people, but cost-wary states must decide whether to take the deal.
Turn it down, and governors risk looking callous toward the needy. Not to mention the likely second-guessing for walking away from a pot of federal dollars estimated at nearly $1 trillion nationally over a decade.
If the Obama administration were to compromise, say by sweetening the offer to woo a reluctant state, it would face immediate demands from 49 others for similar deals that could run up the tab by tens of billions of dollars.
As state legislatures look ahead to their 2013 sessions, the calculating and the lobbying have already begun.
Conservative opponents of the health care law are leaning on lawmakers to turn down the Medicaid money. Hospitals, doctors' groups, advocates for the poor, and some business associations are pressing them to accept it.
"Here's the big thing: The state does not want to expand Medicaid and get stuck with the bill," said Dr. Bill Hazel, Virginia's health secretary.
Medicaid covers nearly 60 million low-income and disabled people but differs significantly from state to state. Under the health care law, Medicaid would be expanded on Jan. 1, 2014, to cover people making up to 138 percent of the federal poverty line, or about $15,400 a year for an individual.
About half the 30 million people gaining coverage under the law would do so through Medicaid. Most of the new beneficiaries would be childless adults, but about 2.7 million would be parents with children at home. The federal government would pay the full cost of the first three years of the expansion, gradually phasing down to a 90 percent share.
The Supreme Court said states can turn down the Medicaid expansion. But if a state does so, many of its poorest residents would have no other way to get health insurance. The subsidized private coverage also available under Obama's law is only for people making more than the poverty level, $11,170 for an individual. For the poor, Medicaid is the only option.