The folly of failing to expand Medicaid, as outlined in the federal Affordable Care Act, was underscored again this week with the publication of yet another study of the consequences.

Leaders in more than a dozen states have refused to expand eligibility criteria to let more uninsured, lower-income residents enroll in the government-sponsored health coverage. Last year, the U.S. Supreme Court provided that option in upholding the constitutionality of the health insurance overhaul.

The lead author of the latest study, conducted by the RAND Corp., noted that residents in every state will pay the taxes associated with implementation of the Affordable Care Act, regardless of whether they expand Medicaid. Researchers evaluated 14 states – not including Virginia – seen as least likely to expand the program because of their governors' opposition.

The financial toll is significant. Those states are poised to lose $8.4 billion annually in federal payments, and could have to spend another $1 billion to treat the uninsured, according to findings published in the journal Health Affairs. The human toll, too, is staggering: With 3.6 million people more left uninsured, an estimated 19,000 deaths could result annually due to lack of care.

"States that do not expand Medicaid will not receive the full benefit of the savings that will result from providing less uncompensated care," said Carter Price, the study's lead author. "Furthermore, these states will still be subject to the taxes, fees and other revenue provisions of the Affordable Care Act, without reaping the benefit of the additional federal spending."

Still, many Republicans have maintained their opposition, including in Congress, where the House has held three dozen votes to repeal the law. These legislators, and their counterparts in state capitols, are shirking their fiduciary duty. Voters appear to be catching on.

A recent survey by the Joint Center for Political and Economic Studies showed a majority of residents in Deep South states – Georgia, Alabama, Louisiana, Mississippi and South Carolina – actually favor Medicaid expansion, despite their leaders' strident opposition.

Virginia lawmakers established a commission this year to determine whether to expand Medicaid, a move that allowed General Assembly Republicans and Gov. Bob McDonnell to defer a decision until federal officials accept a series of cost-cutting reforms.

The strategy is just as misguided as outright refusal. Virginia, previous analyses have shown, would get back nearly all of the tax dollars its residents pay over the next several years if the commonwealth expands Medicaid.

While the cost of Medicaid is generally split between states and the federal government, expansion under the ACA would be entirely covered by the federal government for three years, then gradually phase to 90 percent by 2021.

That time period is critical for at least two reasons. First, states would provide health coverage for more residents without paying more for three years, and in fact, would save millions of dollars that they now spend on treatment of the uninsured and indigent.

Second, as a study by Virginia Commonwealth University's medical school has shown, an uninsured person's health care costs decrease dramatically over the first three years in which he or she obtains coverage. That's because regular access to care helps to better manage chronic conditions and draws patients to family physicians rather than hospital emergency rooms.

In short, failure to expand Medicaid is not only unwise; it is indefensible, on both moral and financial grounds.