House Speaker William Howell (R-Stafford), right, talks with House Appropriations Committee chairman, Del. Chris Jones (R-Suffolk) at the Capitol in Richmond on Wednesday. (Steve Helber/AP)

Virginia House Speaker Bill Howell (R-Stafford) is leading the campaign to block Medicaid expansion even though the largest hospital in his Fredericksburg district says it desperately needs the money to continue supporting health care for the city’s poor.

Fred Rankin, chief executive of the nonprofit parent of Mary Washington Hospital, said rebuffing expansion would cost his institution $14 million a year available under the Affordable Care Act. That would threaten the hospital’s support for a free clinic and community health centers that serve low-income people.

“The stakes are dramatic,” Rankin said. “Those safety net programs are in jeopardy.”

Rankin also said he knows Howell well but is baffled by the legislator’s inflexibility.

“We have disagreed over the years, but I have always found him to have an open mind and be willing to compromise,” Rankin said. “This time, it appears that he is really drawing the line in the sand around no compromise. . . . It’s a behavior I haven’t seen in the past.”

Howell’s spokesman, Matt Moran, responded by citing the GOP’s call Tuesday for a special General Assembly session to discuss Medicaid expansion.

“How can we be refusing to compromise, when we are willing to hold a special session on the very issue they’re talking about?” Moran said.

But the appeal for a special session is just a legislative maneuver — a smart one, admittedly — to reduce the Democrats’ leverage by trying to pry the Medicaid issue away from the rest of the budget. Moran made clear that Howell had no appetite for yielding on substance.

“The speaker’s position has been very clear with respect to Medicaid expansion as a whole. Obamacare has proven to be disastrous,” he said.

Unfortunately for Virginia’s hospitals and working poor, Howell has plenty of company. A decisive number of other House Republicans oppose expanding Medicaid, even though it would disproportionately help their constituents.

The latter is true because many Republican delegates represent mostly rural areas and small cities in southern and southwestern Virginia with a comparatively high share of low-income residents.

Of the 50 House districts with the highest percentage of Medicaid recipients, 32 are represented by Republicans, according to a study by three political scientists at the University of Mary Washington.

Those legislators are willing to forgo the federal largesse rather than risk a primary challenge by tea party candidates accusing them of betraying the conservative cause.

“Many of the Republicans in these districts are in a very tough spot,” University of Mary Washington professor Stephen Farnsworth said. “The message on Obamacare in Republican circles has been no collaboration, no cooperation.”

Opponents object mainly that the U.S. budget deficit is so large that it’s imprudent to expect the federal government to fund a broader Medicaid program for the long run.

But Virginia could drop the plan if Uncle Sam reneged. Why not accept the $5 million a day that’s being offered?

The GOP position is maddening to health-care providers in economically struggling communities such as Danville, on the North Carolina border. The city of 43,000 suffers some of the state’s highest unemployment rates since textiles and furniture jobs went overseas.

Piedmont Access to Health Services, or PATHS, which runs four health centers for low-income people in the area, said 5,000 of its 12,000 patients would obtain health insurance under Medicaid if the program were expanded.

“They have to choose now between, ‘Am I going to pay my rent, buy food or buy health insurance?’ ” PATHS chief executive Kay Crane said.

Danville’s delegate, Danny Marshall III (R), opposes Medicaid expansion.

Our region, because of its comparative affluence, would suffer less than most if Medicaid expansion is rejected. But such a decision still would be a burden to area hospitals.

Inova, a large nonprofit system operating five hospitals in Northern Virginia, would forgo about $100 million a year. It would hire fewer doctors, buy less equipment and cut back on research.

“All of those things get brought under pressure, and you’re forced either to trim them back or slow their growth,” Inova chief executive Knox Singleton said.

He noted the consequences would be more dire elsewhere.

“In any community in southwest Virginia, you’re talking survival of the hospital,” Singleton said.

It’s too bad most of the legislators there care more about sending a political message.

I discuss local issues Friday at 8:50 a.m. on WAMU (88.5 FM). For previous columns, go to