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But other state officials are saying they will study their options and wait until after the November elections to decide. If Republican Mitt Romney wins the White House and starts dismantling Obama’s law, opt-out states might not have to face the Medicaid doughnut hole. But the whole calculation changes if Obama is re-elected and his overhaul starts looking more and more like a done deal.

If that happens, some experts expect that states now refusing will try to cut deals with the federal government, angling for concessions on the expansion itself or the rest of their Medicaid programs.

“One of the things that happens in cases like these is negotiated settlements with specific states,” said Dan Mendelson, president of Avalere Health, an analytical firm serving health care industry and government clients. “What I expect to happen here is that the federal government is going to be more flexible and allow states to do the expansion in ways that suit them.”

It’s hard to see that happening now. Opponents of the health care law are as adamant as ever, even after the Supreme Court upheld most of it, including the mandate that most Americans carry health insurance or pay a fine.

“I will not be party to socializing health care and bankrupting my state in direct contradiction to our Constitution and our founding principles of limited government,” Texas Gov. Perry said last week. About one-fourth of Texas residents are uninsured, the highest percentage of any state.

But John Hawkins, top lobbyist for the Texas Hospital Association, says his group isn’t dropping the subject.

“We have told the governor we are willing to continue the discussion,” said Hawkins. “It’s hard to imagine how you get from here to there without accessing federal funds at some level.”