I'm pretty sure some states (conservative) reject federal medicaid dollars simply because they are ideologically opposed to government funded healthcare.

It's not hard to imagine these same states make the bureaucracy of obtaining low income healthcare benefits arbitrary, difficult to navigate, and counter-productive as way to 'prove' government healthcare doesn't work.

Oh that's one of the big hidden costs is just the amount of paperwork ( in many cases physical paper ) to document, submit in triplicate, and then waiting and waiting and waiting