Republican-led states that expanded Medicaid are sticking with the change, despite qualms and intense political pressure within the GOP about embracing a key part of President Obama’s health-care law.

GOP governors and legislators have balked at repealing expansion partly because of the benefit of providing federally funded health insurance to large numbers of constituents, analysts say.

They also wish to keep the billions of dollars of federal funds that the Affordable Care Act (ACA) — also called Obamacare — gives states that broaden Medicaid.

Even Kentucky Republican Matt Bevin, who won the governorship on Tuesday after campaigning hard against Obamacare, has sent mixed signals about whether he would seek a full repeal that would strip 400,000 Kentuckians of insurance.

Bevin has suggested he might settle for replacing the current program with a less generous model, as six other states have done — with the Obama administration’s consent — to assuage conservative concerns.

Supporters of the Affordable Care Act hold up signs outside the Supreme Court in June 2015 as the opinion for health care is reported. (Jacquelyn Martin/AP)

The ACA, more than any other issue, has rallied conservatives, and Republicans regained control of the House in 2010 and the Senate in 2014 in part on promises to repeal the act.

But of the 10 states in which Republican governors expanded Medicaid, none has backed out in the face of frequent efforts by GOP legislators to reverse the decision.

The pattern appears to confirm opponents’ fears that once states have been seduced into expanding Medicaid, the program proves difficult to repeal.

“Once you step over the threshold and have tens or hundreds of thousands of people getting coverage, it’s very hard to go backward, which is why for opponents it’s a battle to the death to make sure it doesn’t happen in the first place,” said Sara Rosenbaum, a professor of health law and policy at George Washington University.

Broadening Medicaid eligibility remains contentious in many states and in the Republican presidential race, and it was an important issue in Tuesday’s elections in Virginia as well as Kentucky.

Twenty states, mostly in the South, have rejected broadening Medicaid. Experts predict that most will continue to do so at least until partisan passions cool after the 2016 general election.


Still, the trend has been toward expansion. Twenty-nine states, plus the District, have expanded so far, and Montana will do so at the start of 2016.

In the 10 states in which Republican governors initiated expansions, nearly 3 million additional residents received insurance via Medicaid funding between 2013 and 2015, according to a Washington Post analysis of enrollment figures compiled by the Kaiser Family foundation.

An additional 2.2 million people are now on the rolls in eight other states where the governors are Democrats or independents and where Republicans control at least one legislative chamber.

This year in Indiana, Gov. Mike Pence (R) and a GOP-controlled legislature adopted a modified version of Medicaid expansion. Expansion also took place in Pennsylvania in February after being approved by Tom Corbett (R) when he was governor and implemented by his successor, Gov. Tom Wolf (D). Republicans control both chambers of the legislature in Harrisburg.

In two states that have kept their expansion, Arizona and Ohio, Republicans hold the governorship and control both chambers of the legislature.

In a telling example of Medicaid’s staying power, Arkansas recently decided to retain its version of Medicaid expansion even after major GOP gains in last year’s state elections.

In his first year as the state’s governor, Asa Hutchinson (R) said he wanted to keep the program at least through 2016 while developing reforms to curb costs. He succeeded a Democrat, Mike Beebe, who had persuaded the GOP-controlled legislature to go along with expansion.

“If we ended the Medicaid expansion and refused to accept those federal dollars, then that is a lot of money . . . being pulled out of our health system,” Hutchinson said in August in announcing his initial decision.

The legislature subsequently voted by a large majority in each house for the third straight year to keep the program. It did so despite grumbling from tea party representatives, who had increased their strength in the elections.

More than 200,000 Arkansans have received health insurance under the measure. One who welcomes the change is carpenter Clayton Johnson, 55, of Pine Bluff. He said he had not had health insurance since the late 1980s, when he lost a job in a paper processing plant.

But Johnson got insurance in the summer of 2014 through Arkansas’s program, which uses Medicaid funds to pay for private insurance policies for the expansion population. It covered all costs for prostate surgery he had in December.

“Before then, I couldn’t really afford the doctor,” Johnson said. “I didn’t have cancer, but I stood a good chance of getting it, the doctor said. . . . I guess it saved my life.”

Another who has benefited is Patricia Proctor of Little Rock, who is registrar at a barber college. Proctor, who is in her early 60s, said she had always had health insurance through her work until she was laid off in 2012 from a position at another local college. Her new job does not offer health insurance as a benefit, so she relies on Arkansas’s health insurance program. It pays for her blood pressure medication, but mainly it brings her peace of mind.

“When you don’t have insurance and you get sick, you worry about how you’re going to pay your bills,” Proctor said. “It relieves me of a whole lot of tension.”

The effects of expansion

Expanding Medicaid, the federal health insurance program for the poor, is one of the main vehicles for reducing the number of uninsured Americans under Obamacare. The law provides for the federal government to bear all the cost of expansion for the first three years for states that expand eligibility to people earning as much as 138 percent of the federal poverty level, which works out to $16,242 for an individual in 2015.

But the Supreme Court’s landmark Obamacare decision in 2012 gave individual states the right not to participate in Medicaid expansion.

It was an easy decision for 17 Democratic-controlled states, such as Maryland at the time, and for the District, to join in the first round of expansion beginning Jan. 1, 2014. Republican governors in seven states broke ranks with the national party and expanded, as well.

Two of those governors, Ohio’s John Kasich and New Jersey’s Chris Christie, are now running for the GOP presidential nomination. They have drawn criticism for embracing part of Obamacare at home, while opposing it at the national level.

But the decision has proved popular in both governors’ home states, where the two have said expansion was a plus for their budgets. Kasich has attracted attention as well for defending the choice on moral and religious grounds as a way to help the poor.

Since the initial expansion, six more states have expanded or approved plans to expand. Republicans were governors of three of those states, and the GOP controlled at least one chamber of the legislature in the other three.

Opponents have warned that expansion would hurt states’ finances in the long run, because Washington will start insisting that states bear 5 percent of the cost starting in 2017, rising to 10 percent in 2020.

However, studies in Arkansas and Kentucky forecast that expansion would be a net plus financially for those states for years to come.

The benefit arises partly because expansion states reap savings as federal dollars replace state ones for a larger share of the cost of some mental health services and for health care for prison populations.

A nationwide Kaiser foundation study released this month found that states that expanded Medicaid fared better financially in the fiscal year ended Sept. 30 than those that didn’t.

Such outcomes have helped lead Republican governors in Utah, Tennessee and Wyoming to press for Medicaid expansion, only to be rebuffed by GOP-led legislatures. Observers think more states will enlarge their programs in the future, but only after a pause for the 2016 campaign to elect a new president.

“It’s election time, and Republicans are still into their anti-Obamacare rhetoric,” said Ron Pollack, executive director of Families USA, which supports expansion. “I think it will be very different from 2017 on. The president will no longer be in office.”

Moderates wary of tea party

In the recent electoral campaigns in Virginia and Kentucky, the debates over Medicaid expansion illustrate the differences over how the issue plays politically, depending on whether the state has expanded.

Virginia Gov. Terry McAuliffe (D) came up short in an all-out push to wrest control of the Senate from the Republicans. The loss marked a major setback for his high-priority effort to expand Medicaid.

GOP candidates across Virginia have come under pressure from business leaders and the health-care industry to support expansion. But they have been unwilling to do so partly out of fear of losing in primaries to tea party challengers, according to politicians and independent analysts.

In two Senate districts where moderate GOP senators who supported Medicaid expansion retired, both Republican candidates who won races to succeed them oppose expansion.

“The problem is that the politics of it in Virginia have become so radioactive,” Sen. John C. Watkins (R-Powhatan), one of the retiring moderates, said. “I don’t think it’s the policy at all. It’s the politics. . . . [Opponents] just don’t want to accept it because a Democratic president had proposed it.”

By contrast, Kentucky’s campaign shows how difficult it is to fully repeal Medicaid expansion once it’s in place, even if a hard-line conservative comes out on top.

There, conservative businessman Bevin had said at the start of the year that he favored immediate, full repeal of Medicaid expansion. By summer, however, he appeared to have softened his position under a barrage of Democratic attacks.

By the end of the campaign, Bevin’s Web site still called for repealing the expansion. But in public statements, he suggested instead he would merely replace it with a more market-friendly model similar to Indiana’s.

“I think somebody talked to Bevin and made him understand the politics of this,” Al Cross, director of the Institute for Rural Journalism and Community Issues, said.

“They might change it to save money, or for ideological reasons, but you don’t take health care away from people,” he said. “It’s just bad politics.”