IF REASON isn’t dead in Virginia, where anti-Obamacare forces are winning a tense battle over health coverage for low-income people, it is at least on life support.

In an intense, sometimes angry, marathon session Thursday and Friday, state lawmakers hashed out a budget that excludes an expansion of the state’s Medicaid program, which would have directed billions in otherwise unused federal money toward Virginians’ health. At this point, Republican holdouts have made more than clear that they oppose President Obama’s health-care reform. They don’t need to keep punishing their constituents to make the point.

The effects of their crusade are severe. The Affordable Care Act offers states money to cover many more people through the Medicaid system. All states need do is accept it and pitch in a small amount to help cover the cost in future years. If Virginia were to take this obvious step, the program would help some 400,000 people hovering around the poverty line, some of the state’s most vulnerable residents. These people don’t have other options under the ACA, because the law envisioned Medicaid expansion happening everywhere. Subsidies to buy health insurance on Obamacare exchanges are available only to wealthier people. The existing Medicaid program covers only poorer people. Without expansion, a large slice of the needy Virginians will be left to fend for themselves.

Moreover, Virginia Republicans’ continuing refusal to accept the federal government’s offer hurts the state’s hospitals. Under the ACA, they are set to lose millions in reimbursements from Medicare, the health program for elderly people. That was supposed to be offset by Medicaid expansion, which would provide hospitals with more paying customers and reduce the amount of uncompensated care they must deliver. Instead, they will be strapped.

For these reasons, Democrats and a handful of sensible Republicans rightly fought hard for Medicaid expansion in Virginia’s next budget. That led to legislative deadlock and talk of a state government shutdown next month. Then, thanks to the surprise resignation of a Democratic senator, Republicans gained control of the state Senate, recalled lawmakers and approved a budget that not only fails to expand Medicaid but also aims to forbid any expansion without their express say-so.

Gov. Terry McAuliffe (D), who made Medicaid expansion his top priority, does not appear to have any attractive options left. He can amend or veto the budget, sending it back to the General Assembly and tempting a shutdown. He can attempt to expand Medicaid unilaterally, which would further poison state politics and invite a legal crisis. Or he can sign the budget and push for expansion separately, with less leverage than he had before.

The only good option is one before Virginia Republicans: Authorize expansion and do the right thing for the uninsured and the hospitals across the state that otherwise will suffer.