Gov. Bill Haslam listens to a question after a speech to a Republican group in Nashville, Tenn., on Dec. 4.

The lamentable spectacle of witless state legislators and myopic protesters urging Gov. Haslam not to establish a state insurance exchange in accord with the Affordable Care Act is sad enough. But if they shun that responsibility and leave it to the federal government to create the state's exchange with higher standards and more competitive comprehensive policies, so be it. That might well be better for the huge number of uninsured Tennesseans who need and deserve access to affordable, comprehensive health insurance.

The larger risk is that Gov. Haslam will refuse to extend Medicaid to people whose income falls between 100 percent and 133 percent of the federal poverty level, and with that action blow off $7.5 billion in federal grants that would come in the first five years alone to support expansion of Medicaid for the most needy Tennesseans. This would be a cruel and heartless travesty, all in the name of blind resentment toward the national health care reform championed, and achieved at long last, by President Obama.

The isolation of people with incomes between 100-and-133 percent of the federal poverty level is an anomaly of the ACA, which envisioned -- and tried to mandate -- expansion of Medicaid to the typically uninsured people in this income group. That seemed fair when the ACA was written. The federal government provides two-thirds of Medicaid funds; the state, the other third. People with incomes above the 133 percent of poverty level cut-off were made eligible under the ACA for wage-adjusted subsidies to help them buy the flat-rate, comprehensive care insurance that will be available to all comers under the competitive, non-profit policies offered through state exchanges beginning in January 2014.

The Supreme Court's June 28 decision approving the ACA, however, negated the federal mandate to states to expand Medicaid. That left it up to states to decide whether to voluntarily enlarge the Medicaid pool, and accept the increased portion of Medicaid funding that would come for that new group of members. The new federal grants for that would be sizable: 100 percent of the increased cost for the first three years, declining to 90 percent after that, and remaining at that point.

The logic for accepting Medicaid expansion is irrefutable. It would ensure preventive care for a significant group of people who otherwise opt for emergency-room care, which is a far more expensive and far less efficient way to obtain health care. It would actually save the state and insured citizens money by vastly reducing the cost-shifting of indigent-care costs for this segment of citizens to government and insurance premiums.

Legislators apparently haven't studied the economics of this equation. If they refuse to expand the Medicaid group, they will essentially make Tennesseans subsidize the funds that other states receive for this expansion, without any benefit for Tennessee.

Worse, they will leave a sizable segment of residents, about 200,000, without health insurance. That would essentially say that they so despise low-income people in this minimum-wage segment that they don't care a whit about their plight; or, that they are so privileged and distant from this class of people that they do not realize the enormity of their health care issues.

Their larger resistance to establishing state exchanges for Tennesseans above 133 percent of the poverty level further symbolizes their disdain for virtually a third of Tennessee's working age citizens below the Medicare-entry age of 65.

Legislators and the governor should learn precisely what groups and numbers of Tennessee have no health care insurance, or are grossly uninsured. The number of uninsured Tennesseans is over 900,000. Discount the number of Tennesseans above the Medicare age of 65; and those below the poverty level who get Medicaid; and the number of children covered by the state/federal CHIPs program for families with incomes up to 300 percent of the poverty level; and consider the fact that nearly half of all employers don't provide affordable-share health insurance; and that most self-employed people can't afford a private policy-- and you are left with the fact that virtually a third of working-age Tennesseans are uninsured, untreated, and vulnerable to medical-cost catastrophe and bankruptcy.

And the majority of Tennessee's legislators don't give a hoot. They rail against the ACA without reason or pertinent facts, and they don't want to help their uninsured citizens. They could not be more cruel or senseless, nor more shameless.