IN REFUSING to expand Medicaid under the Affordable Care Act for the past several years, Virginia Republicans seemed intent on sticking it to President Barack Obama and then-Gov. Terry McAuliffe (D). In fact, they stuck it to themselves, losing 15 seats in this past fall’s elections for the House of Delegates, in most cases to Democrats who promised to expand Medicaid. And the GOP really stuck it to hundreds of thousands of poor and mostly employed working Virginians, especially in rural areas, who lack Medicaid coverage.

That message has now been received by some Republicans in Richmond, but not all. In the House, where the GOP clings to a 51-to-49 majority, a wave of new thinking has prompted Republicans to back a draft budget that would expand Medicaid to cover an estimated 300,000 Virginians, albeit with some conditions. In the state Senate, though, Republicans, who also hold a paper-thin majority in that chamber, seem convinced that they can continue to spurn billions in federal funding and let indigent Virginians suffer the consequences.

Those consequences are considerable. In 2014, the Urban Institute estimated that if Virginia expanded Medicaid, it would incur $1.3 billion in costs over 10 years — but also gain $14.7 billion in federal Medicaid funding, plus $6.2 billion in hospital reimbursements.

In human terms, the beneficial impact of expansion would be enormous, as some influential Republicans have lately acknowledged. One is Del. Terry G. Kilgore of rural Scott County, on the Tennessee border, where, among a rapidly aging population of 22,000, more than 1,000 people would gain health insurance under Medicaid expansion. “For my district, for my part of the state, it’s the right thing to do,” said Mr. Kilgore, who chairs the House Commerce and Labor Committee.

Apparently looking for a political fig leaf, House Republicans yoked their expansion blueprint to a gratuitous requirement that Medicaid recipients, including the 1 million or so existing ones, seek work training — most are already employed — and contribute to their coverage through private insurers. Even with those conditions, there’s no sign of movement yet among Senate Republicans.

All but 18 states, including some with GOP legislatures and governors, have already expanded Medicaid. The logic of expansion is compelling: At least 90 percent of the cost is borne by the federal government. In the past, Republicans who opposed Medicaid expansion warned that states would be left holding the bag if Congress cut off aid. But Congress hasn’t done so, and the Virginia House bill includes a “kill clause” that would rescind expanded coverage if the federal funds dried up. In the state Senate, Republicans have run out of excuses for refusing to help their neediest constituents.

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