Texas will not be able to opt out of participating in Obamacare, despite Rick Perry's avowed claims to the contrary.
Texas has the highest rate of uninsured citizens in the country. Not coincidentally it also has one of the highest costs per hospital for providing unpaid care to its uninsured residents that show up in the Emergency room for non-emergent care as well truely urgent care. Obamacare largely eliminates this loss from their future balance sheets.
In addition the flow of federally paid Medicaid dollars to the state under Obamacare is critically important to the survival of many hospitals, particularly in small town and rural locations.
Their are 667 hospitals in the state of Texas according to the American Hospital Directory (ahd.com). These hospitals range in size from less than 100 beds up to approximately 1400 beds in size. Individually their yearly gross revenues range from on the low end approximately 100 million dollars, up to several billion dollars. For example, Baptist in San Antonio earned more than 3 billion dollars in gross revenue and more than 100 million in net income in their latest report in the American Hospital Directory.
Simply put, the wealth and economic power of the 667 hospitals in Texas is several times that of all the Kochs, Adelsons and other billionaires in this country combined. In Texas (as most places) money talks and Rick Perry always listens. The 667 hospitals in Texas and the hugely influential Texas Hospital Association will win this battle and Rick Perry will lose.