THE SECOND SECESSION CONTINUES

Abortion is theoretically legal nationwide, but it's widely available in only some states, and it soon won't be available at all in some. Gay marriage will probably soon be legal in many states -- and will probably never be legal in others. Up here in the Northeast, we have gun laws; in most of the country, it's a firearms free-for-all.

And now, as ProPublica, The Wall Street Journal, and The New York Times have noted in the past couple of days, it's quite likely that many states of the Union simply won't go along with the Medicaid expansion in the health care law, thus continuing the process of turning America into two nations engaged in -- to use a phrase I didn't coin -- a cold civil war:

Millions of poor people could still be left without medical insurance under the national health care law if states take an option granted by the Supreme Court and decide not to expand their Medicaid programs, state officials and health policy experts said Friday.

Republican officials in more than a half-dozen states said they opposed expanding Medicaid or had serious doubts about it, even though the federal government would pick up all the costs in the first few years and at least 90 percent of the expenses after that.

... already, governors in Kansas, Nebraska and South Carolina, among other states, have said they would have difficulty affording even the comparatively small share of costs that states would eventually have to pay.

... In New Hampshire, State Representative Andrew J. Manuse said he and other Republicans were already working to block the expansion of Medicaid....

Striking down the Medicaid provision was an act of evil genius, because the middle class never seeks to fight for benefits for the poor. The issue now ceases to be "coverage for everybody" and becomes "coverage for them." Even in blue and purple states, governors and legislators who fight for universal coverage are going to be attacked as evil taxers and job-killers; this is the perfect issue to get another round of Chris Christies and Scott Walkers elected.

Oh, and as Politico notes, there are going to be many Republican refuseniks preventing their states from setting up health care exchanges. This might not mean much -- the feds are supposed to set exchanges for states that refuse to do so themselves -- but it's one more way this law is starting to seem like Brown v. Board or school busing, a federal requirement that's going to lead to massive resistance at the state level.

On the Medicaid front, as the Times reports, there is the possibility that there'll be pressure on reluctant states to go along with the expansion -- and guess what the source will be:

Health care providers who treat low-income patients strongly support the expansion of coverage.

Richard J. Umbdenstock, the president of the American Hospital Association, said that hospitals around the country would lobby for the Medicaid expansion....

Nancy M. Schlichting, chief executive of the Henry Ford Health System in Detroit, said she "absolutely will lobby" for the expansion of Medicaid. She said she expected Gov. Rick Snyder, a Republican, to support the expansion, but she added, "he may have trouble" getting it through the Michigan Legislature.

Is near-universal coverage going to happen only because the fat cats of Big Medicine lobby for it? Maybe.