Step 4: Every 10 years, the allocation of our 435 members of the House looks at who lives where and reassigns districts based on population density. The census numbers reflect the shift. The state that did not expand Medicaid surrenders a member of Congress, and loses political power.

Possible? You bet. It's even more probable in the Midwest/Northeast, which have already been losing representation in population shifts for decades. Most at risk are these states: Indiana (not expanding), surrounded by Illinois, Kentucky and Michigan, which are.  Ohio (not expanding), surrounded by Michigan, Kentucky, West Virginia and Pennsylvania, which are.  Utah (not expanding), surrounded by Nevada, Arizona and Colorado, which are. 

And a special case of South Dakota (not expanding) next to North Dakota, which is. What if South Dakota loses enough population to drop below the threshold needed to maintain state status, and reverts to "Dakota Territory." Hmmm.  Perhaps that would free a star up on the American flag, so Puerto Rico could become a state.  Just thinking …

But, I digress. There are other demographic impacts of the Medicaid decision. Talking with friends in the hospital business, those in states with no Medicaid expansion are scared that they will continue to have their ERs slammed with the indigent, while losing federal subsidies as a part of the ACA's grand plan.  Somewhat counterbalancing this will be the concept of "adverse selection," where the low-income population that moves for healthcare insurance will be more likely to be high consumers of health services, so the remaining population may have fewer chronic health issues. We'll see.