Conservative Republican governors Jan Brewer of Arizona, Rick Scott of Florida and John Kasich of Ohio are battling with their own party members over their efforts to accept a huge influx of federal dollars and provide health coverage to poor people. So far, the governors are losing.
Republican governors in eight states made waves when they embraced an expansion of Medicaid, a core component of President Barack Obama’s health care reform law. However, GOP legislators have been cool to the plans -- saying they're unaffordable, despite unprecedented federal funding.
This Republican infighting threatens to deny millions of people access to medical care and the financial security that comes with health care coverage. The standoff also imperils the prospects that Obama's sweeping overhaul will fulfill one of its most important promises: that low-income adults largely shut out of today's health insurance market because of cost will gain access to health benefits.
"Florida lawmakers have just an incredible opportunity in the palm of their hands to provide health coverage to a million working Floridians, and it would not cost Florida anything for the first three years," said Leah Barber-Heinz, the advocacy director for the Florida Community Health Access Information Network. "We are surprised there is even still a debate going on."
Under Obama's health care law, the federal government will pay the full cost of opening Medicaid to anyone who earns up to 133 percent of the federal poverty level, which is $15,282 for a single person this year, from 2014 through 2016. Over time, that share will decline until it reaches 90 percent in 2022 and future years. That compares to the average 57 percent of the costs the federal government pays states for people currently on Medicaid. States don't face a deadline to decide on the expansion.
The Medicaid expansion was supposed to take effect nationwide, but the Supreme Court disrupted Congress' plan last June when it ruled states could decline to broaden the program, which the federal and state governments jointly run and finance.
More than a dozen Republican governors, including Rick Perry of Texas and Bobby Jindal of Louisiana, oppose the Medicaid expansion. The chief executives of 26 states and the District of Columbia support the expansion, but legislatures with Republican majorities have effectively killed their plans in a number of states, including Michigan, Missouri and Montana. To date, the only GOP-led legislatures to approve expansions are in Arkansas and North Dakota.
Republican state lawmakers hostile to Obamacare aren't persuaded by their GOP governors -- and are under pressure from tea party-affiliated groups like Americans For Prosperity, which campaigned last year against Republican and Democratic candidates it viewed as pro-Obamacare.
"It's been extremely difficult for people who were at one time on the record opposed to the Affordable Care Act to be able to support this," Barber-Heinz said.
Arizona state Rep. John Kavanagh (R) confirmed that Medicaid is just one front in the war against Obama's health care law. “This is clearly an extension of Obamacare,” said Kavanagh, the House Appropriations Committee chairman. “We don’t believe in this mass takeover by government of the health care industry.”
And while the standoff between Republicans continues, 21-year-old Victoria Lofters of Ft. Lauderdale, Fla., and others like her, can do little but wait.
Lofters is an uninsured student at Broward College who works three jobs and is trying to pay down the more than $20,000 in medical debt she owes from ongoing treatment for ovarian cysts and a bout with gastritis. Doctors have warned the cysts could progress into cancer or burst. But her condition is going largely untreated because she can't afford the medical care.
"Me and many other of my peers fall into this category," said Lofters, who earned about $13,000 in 2012 and estimates she's visited hospital emergency departments for health care more than 40 times over the past year.
In 2011, 3.8 million Floridians, or 20 percent of residents, had no health insurance, giving the state one of the highest rates of uninsured people in the nation, according to census data. A Medicaid expansion would cover 1.3 million people, the Urban Institute and the Henry J. Kaiser Family Foundation estimated last year.
"I'm busting my you-know-what to make it happen for myself, and I'm still barely making it," said Lofters, who said she's one of the first women in her family to enroll in college and hopes to earn a Ph.D. in occupational therapy. "I'm trying to become a productive citizen."
Lofters worries her plans for the future will be derailed by poor health or the burden of medical debt. "What if one day, I'm just so sick I can't do anything? What if I can't go to school, what if I can't work? What would I do? It brings tears to my eyes because I don't want to be that way."
In addition to financing health care coverage for uninsured poor residents, Obamacare's Medicaid money would flow through states' hospitals, let employers off the hook for providing health benefits, allow state and local governments to cut back on programs that would become redundant, and enable states' residents to see some of their federal tax dollars go to their neighbors.
"Any time Washington wants to give us money, it is my opinion and the opinion of others that they're giving our money back to us that's owed to us. It disappoints me that my colleagues and others don't get that," said Florida state Rep. Mike Fasano. Fasano is the leading House Republican pushing for an expansion supported by Scott but opposed by Florida House Speaker Will Weatherford (R) and other leaders. Weatherford, 33, is viewed as a likely statewide candidate in 2018 in a state where the tea party seized control of the 2010 GOP primaries.
A coalition of Florida Senate Republicans and Democrats wants to approve a form of expansion that would use the Medicaid dollars to purchase private health insurance, similar to the plans adopted in Arkansas and sought by Kasich in Ohio. Arizona's Medicaid program already provides coverage through private health plans.
Arkansas' Republican-led legislature adopted Gov. Mike Beebe's (D) proposal with more than three-quarters of the vote this month. Kasich hopes the approval could spur action in Ohio, where legislators have blocked his similar plan so far, said Greg Moody, the director of the Ohio Office of Health Transformation.
Like other Republicans, Kasich opposed Obamacare. But he sees the expansion as an opportunity to reform Ohio's Medicaid program and is seeking a privatized option to appeal to Republican legislators, Moody said.
"It was a constant kind of careful negotiation to try to understand what our very conservative House, particularly, would find more appealing than the Medicaid-only option, but at the same time be in a range that the federal government would ultimately approve," Moody said.
In Ohio, 1.5 million people, or 14 percent, had no health insurance in 2011, census figures show. According to the Urban Institute and the Kaiser Family Foundation, expanding Medicaid would extend coverage to 684,000 people.
Kasich helped assemble a broad coalition to support his Medicaid plan, including business leaders, hospitals and health care providers, and activist organizations usually more affiliated with Democrats, Moody said. Similar interest groups have backed the Medicaid expansion elsewhere.
But not enough GOP legislators are swayed by their arguments so far, Moody said. "It's been a bit of a roller coaster."
In Arizona, the Republican resistance to Brewer’s plan has led her to an unusual alliance with House Minority Leader Chad Campbell (D), her longtime nemesis, and Democrats make up the base of Brewer's support on Medicaid. Campbell is confident the plan could pass via an alliance of Democrats and moderate Republicans, but GOP lawmakers dispute that claim.
The conservative Republicans who control the Arizona Legislature have revolted against Brewer. Kavanagh said Medicaid funding isn't sustainable and fears devastating economic consequences from federal spending -- while acknowledging the immediate benefits a Medicaid expansion could create for his state. “It brings in money to Arizona, but at what cost?” he said.
Campbell dismissed Republican objections about spending. “For all the arguments I hear about the federal government not being able to afford it, I don’t see them rejecting federal money for highways or border security,” Campbell said. “They are willing to throw away health care for people and can cost this state thousands of jobs.”
The uninsured rate in Arizona was 18 percent, and 1.2 million residents lacked health insurance in 2011, according to census data. The Obamacare Medicaid expansion would provide benefits to 238,000 people, according to the Urban Institute and Kaiser Family Foundation project.
The stalemate between Brewer and GOP lawmakers has consumed the Capitol, but she won't give up until the Legislature delivers a plan, said Matt Benson, her spokesman. "She’s patient," he said.