Despite a lot of posturing and complaining, the Republican opponents of the Affordable Care Act (ACA) are relatively limited in what they can do to prevent implementation of Obamacare. Sadly, however, there is one aspect of the law that Republicans at the state level have demonstrated that they’re eager to fight back against, and—no big surprise—it’s the one that affects some of the most financially needy Americans: Medicaid expansion. The Supreme Court ruled last year that the provision—which would require states to expand Medicaid to cover people up to 133 percent of the poverty line—is optional, and so far 21 states have decided to opt out.

The result, according to ThinkProgress’ Sy Mukherjee, will be devastating. Mukherjee reports on a new study by the Commonwealth Fund, which shows that these Medicaid expansion refusals could result in up to 42 percent of the people living in those states who went uninsured at some point in the past two years being left out of Obamacare. As the unemployment rate continues to hover above 7 percent, the chance that this giant hole in coverage will somehow resolve itself through employment for the poorest Americans seems like a long-off fantasy.

Make no mistake: The only reason Republican-led states are doing this is out of an ideological distrust often bordering on hatred of the working class. According to the relentless drumbeat of conservative media outlets like Fox News, people who require government help to survive are just lazy leeches who think they’re too good to fight for a better-paying job. But the second that the lowest-income Americans do stand up for themselves and demand better pay so that they don’t have to go on Medicaid and food stamps, the very same conservatives angrily denounce them for that too. You’re a bad person if you need help. You’re a bad person if you seek a job with a living wage. Given the conservative mentality, there’s nothing people can do to win.

The refusal to accept the Medicaid expansion cannot be justified through the usual half-baked conservatives rationalizations. It doesn’t save the states any money to refuse it; the expansion is to be paid for almost entirely by the federal government. In other words, taxpayers in those states will pay the same taxes as everyone else, but their states will get less in return. That means it is costing the states money to refuse the Medicaid expansion. And that’s all before the excessive health costs that end up falling on taxpayers when people who don’t have insurance end up in emergency rooms, often because they couldn’t afford preventive care. In addition, refusing the Medicaid expansion reduces the amount of competition on the insurance market, meaning that even well-off Americans in red states will be paying more for insurance.

In other words, given a choice between saving their states and their taxpayers money and deliberately forcing lower-income Americans to go without health care, most Republican state governments have chosen the latter. (Though not all—Arizona, New Jersey, Iowa, and North Dakota all have Republican governors who decided they want a better-run state more than they want to stick it to the poor.)

Women are going to be badly affected by this petulant screw-the-poor grandstanding on the part of Republican state legislators and governors. This January, the American College of Obstetricians and Gynecologists issued a press release pointing out that 19 million women are uninsured and that the Medicaid expansion could change that. Because of the holes in insurance coverage in the current system, there’s a much higher incidence of bad outcomes with sexual and reproductive health than there should be. Some direct statistics quoted from the press release:

Uninsured pregnant women receive fewer prenatal care services than insured women and are more likely to experience adverse maternal outcomes such as pregnancy-related hypertension and placental abruption. Adverse outcomes, such as low birth weight and infant mortality, also are more common among uninsured women. Improved maternal and fetal outcomes occur with access to high-risk pregnancy care, counseling, and other enabling services. … Inadequately addressing pregnancy complications may have disastrous long-term emotional and economic effects on families. Society may face unintended increased costs to provide medical services to care for children born to uninsured women who have pregnancy complications.

Uninsured women are less likely than insured women to use prescription contraceptives, partly accounting for adverse reproductive health outcomes, including elevated rates of unintended pregnancy and abortion in poor women …

Uninsured women with breast cancer are 30–50% more likely to die from cancer or cancer complications than insured women with breast cancer …

Uninsured women are 60% more likely than insured women to receive a diagnosis of late-stage cervical cancer.

One of the ACA’s great benefits to women of reproductive age is access to birth control without a co-pay. While contraceptive use was already improving in the population writ large—particularly among teens—lower-income women still have serious problems preventing unintended pregnancies, in no small part because paying out-of-pocket for contraception is often out of reach. Pills sometimes have to be skipped because you can’t afford them this month, and while condoms may seem cheap to middle-class Americans, a box of them at the drugstore costs as much as what is supposed to be three days worth of food on food stamps. When you’re living so close to the edge, being able to scrounge up enough for contraception is a touch-and-go thing, which is no doubt why unintended pregnancy rates are going up for lower-income women even as they go down for everyone else.

With one swift, cost-effective move beneficial to both taxpayers and public health alike—embracing the Medicaid expansion—Republican governors can help close the health-care gap between low-income Americans and everyone else, a gap that currently contributes to more unwanted pregnancies and more abortions. They must stop posturing to win the accolades of right-wing media who enjoy the idea of starving out the poor for the simple sadistic pleasure of doing so.