Gov. Rick Perry has promised to fight tooth and nail against implementing the Affordable Care Act. But that doesn't mean big changes aren't coming to Texas health care, and it won't save lawmakers from facing tough spending decisions.

Texas has about 6 million uninsured residents, which comes out to nearly a quarter of its population - higher than any other state.

For the 2014-205 budget cycle, the Texas Health and Human Services Commission that runs the Medicaid program has asked the Legislature for an additional $6.7 billion. Republican leaders, meanwhile, have already pledged to increase the entire state budget by only $7 billion.

If they plan to maintain their spending cap, they will need to pare down spending on health care.