UPDATE: “Pennsylvania won federal approval to expand its Medicaid program to nearly 500,000 low-income adults on Thursday, becoming the ninth state led by a Republican governor to join the expansion under the president’s health-care law,” Jason Millman reports. There are now 26 states and Washington, D.C. that have chosen to do so.  

The bargain goes like this: The federal government wants to pay your state to get more low-income adults on Medicaid. For now, it will completely cover the cost of giving these people healthcare, which adds up to billions of federal dollars flowing into your state. (In a couple years, the feds will expect your state to chip in 10 percent.)

The catch: If your state’s politicians agree to take the money, their Republican buddies might accuse them of supporting Obamacare.

And so half of all states, all of them either divided or under Republican control, have turned down the federal money. This is an example of how politics sometimes force Pyrrhic choices.

Some have justified the decision by arguing that Medicaid expansion would be a false economy. “Medicaid expansion is bad for states because it would put a tremendous strain on state budgets and increase dependency on government programs,” wrote Florida Gov. Rick Scott in a 2012 op-ed. Scott pointed out that states would eventually have to pay that 10 percent, which he said could become a burden.

But even Scott found it hard to say no to the billions of federal dollars that would accompany expansion. Eventually, he came out in favor of a three-year temporary plan, to take advantage of these years during which the federal government has promised to pay for 100 percent of the expansion costs. In return, the Obama administration agreed to let Florida privatize Medicaid.

It wasn’t enough. The Republicans in Florida’s legislature still shot down that plan.

Other Republican states have found success in wringing concessions from the Obama administration. For instance, instead of expanding Medicaid, Arkansas is using its Medicaid expansion dollars to help the poor buy private insurance on Obamacare’s exchanges. This is a more palatable arrangement for the state’s GOP lawmakers. Iowa and Pennsylvania both want to do something similar. (Iowa’s plan was approved and Pennsylvania’s plan is still in the process.)

If she chooses to live in Virginia, a non-expansion state, Liz Church might not ever get back on Medicaid. The new Democratic governor, Terry McAuliffe, made a campaign promise to expand the program, but he’s battling opposition in Virginia’s legislature. So far, the saga includes a break-in at the governor’s office and a narrowly averted government shutdown. With both houses in GOP hands, McAuliffe has threatened to go it alone if need be—though whether that’s constitutional remains to be seen.