That is why its unattractive.
But with the Medicaid expansion a governor has to tell his voters :”Sorry, I know that allowing you to have medicaid would cost our state nothing, but I am against it. You always have the emergency room if you get real sick, Just throw away the hospital bills for that if you cant afford them”
In bright red states its no problem to say that, on AM radio too.
In Blue or purple states like VA it doesnt go over very well.