Adam Abernathy (L) listens to a doctor's instructions as he waits to receive a donated kidney as part of a five-way organ transplant swap in New York, August 1, 2012. Abernathy's partner David Ferguson donated a kidney for transplant to a stranger while at the same time someone else donated a kidney to Abernathy as part of chain of kidney donations that allow five people to receive a transplanted kidney over a two day period. The health dangers for kidney donors is believed to be low. The risk of death from the surgery is 1 in 1,700, according to the National Kidney Foundation, and life expectancy is said to be unchanged with one kidney. Picture taken August 1, 2012. To match story USA-KIDNEY/SWAP REUTERS/Keith Bedford (UNITED STATES - Tags: HEALTH SOCIETY)
The issue is whether or not to expand Medicaid, the federal-state health program for low-income people.
More than 15 million uninsured people are expected to gain coverage through Medicaid under President Barack Obama's health care law.
States are free to turn down the expansion, but the choice isn't easy.
Governors worry about costs. But if they say "no," they risk coming off as callous toward their neediest residents. Not to mention the second-guessing for walking away from a pot of federal dollars estimated at nearly $1 trillion nationally.
The coverage expansion doesn't happen until 2014, but the debate in state capitals starts now.
It's health care brinksmanship, with billions of dollars and the well-being of millions of people at stake.