Regardless of the outcome of the troubled Obamacare rollout, a key uninsured population will remain out in the cold: the very poor living in Republican-dominated states. At press time, 25 states, largely controlled by GOP governors, had exercised their U.S. Supreme Court–validated right to opt out of the health care law’s expansion of Medicaid coverage.

Obamacare provides subsidies to help make private health plans more affordable for those living between 100 percent and 400 percent of the federal poverty level. Anyone making less than 138 percent FPL qualifies for expanded Medicaid. But without expanded Medicaid in a particular state, there will remain a gaping hole in coverage for anyone making less than 100 percent FPL ($11,490 for an individual and $19,530 for a family of three) but more than the income ceilings for traditional Medicaid coverage, which are often rock bottom in those 25 states.

“The Medicaid expansion is the game changer that the HIV community fought for to expand access to care for low-income people living with HIV,” says Amy Killelea, associate director of health care access at the National Alliance of State and Territorial AIDS Directors. “And in states that do not expand, not only are we leaving low-income people living with HIV out of reform, we are widening already significant geographic health care disparities.”

The Deep South has proved uniformly stubborn in its refusal to expand Medicaid, a fact that is particularly troubling to HIV advocates such as Killelea, considering the disproportionate impact of the epidemic in that region.