DALLAS – This is not shaping up as a dream week for Texas Gov. Rick Perry. Monday morning headlines state the obvious: He won’t be playing a major role at the Republican National Convention in Tampa.

Meanwhile back home, there's a small-scale mutiny afoot as some larger counties are openly resisting Perry’s pushback against President Obama’s plan to expand Medicaid as part of health care reform.

Perry, of course, is among a handful of Republican governors who’ve said their states won’t participate in the Medicaid expansion. Even though he’s no longer in the presidential contest, the stance gives Perry a platform for continuing to criticize Obama, saying the plan is too expensive and has too many federal strings attached.

Whether that stance is strictly partisan politics, or deeply felt principle, is in the eye of the beholder. For its part, the U.S. Supreme Court recently ruled that states can opt out without penalty from the federal government.

But some Texas counties may be more focused on the bottom line than on the political implications of accepting dollars from Washington. That’s because the state’s largest counties already wind up absorbing much of the cost of care for people who can’t pay.

When people without health insurance – now one in four Texans, I’m sad to say – show up in the emergency rooms of the large urban public hospitals, they can’t be turned away.

And if they can’t pay, the hospital districts, which are supported in part by tax dollars, absorb the costs.

It shouldn’t be surprising then, that some of the large urban hospitals have been talking among themselves about trying to snag the federal Medicaid dollars Perry wants to spurn.

In San Antonio’s Bexar County, about half the people who get county-paid health care would be eligible for money from the Medicaid expansion, officials say. That translates into a savings of $53 million per year for the county.

George Hernandez Jr., chief executive of University Health System in San Antonio, is credited with coming up with the plan. Officials there say peers in Fort Worth, Dallas and Houston have shown some interest.

However, creating a county-run Medicaid program would require not only approval from the White House, but from the Republican-controlled Texas Legislature. What are the odds of the Lege bucking Perry?

And even if that were to happen, the Medicaid expansion calls for full federal funding for only the first three years, beginning in 2014. After that, feds would fund 90 percent, and counties would be responsible for the 10 percent match.

Where the money would come from is an open question, as is the prospect of having different levels of care and coverage among the state’s 254 counties.

What’s clear, for now at least, is that Perry does not speak for all Texans when it comes to federal Medicaid dollars. With 24 percent of the state’s residents lacking health insurance, the highest rate in the country, it makes sense for counties to reach for federal dollars.

Lori Stahl covers politics and culture in Texas. Follow her on Twitter @LoriStahl.