To hear the advocates of expanding Medicaid tell the tale, Virginia and other states would be dumber than a sack of hammers to turn the idea down. It is, proponents say, a win-win situation: The state gets to increase insurance coverage for tens of thousands of people—and hand the bill to the federal government. Throw in the savings from the economic stimulus from all that new money, along with offsetting cuts elsewhere, and the state comes out a clear winner.

But it’s a rare coin indeed that has only one side, writes A. Barton Hinkle. Flip this one over, and expanding Medicaid doesn’t look quite so wonderful. Here are three reasons why.