Ohio Gov. John Kasich is among several GOP governors criticizing the Senate Republicans’ health-care legislation. (Ron Schwane/AP)

Several moderate Republican governors are expressing reservations about the health-care bill unveiled in the Senate Thursday, further complicating efforts by GOP congressional leaders to make good on their promise to end the Affordable Care Act.

John Kasich of Ohio, Brian Sandoval of Nevada, Charlie Baker of Massachusetts and Larry Hogan of Maryland issued separate statements criticizing aspects of the legislation, including the secrecy under which it was written as well as the impact it would have on state budgets and low-income residents.

All four hail from states that expanded Medicaid under the ACA and have received billions of federal dollars to help them cover more low-income Americans. The Medicaid program, which traditionally encompassed poor children and their parents, pregnant women, people with disabilities and the elderly, is administered jointly by the state and federal governments.

Thirty-one states and the District of Columbia opted into the expansion, leading more than 11 million able-bodied adults to gain health coverage. These states have the most to lose under the Senate bill, which would end federal support for the expansion in 2024 and force states to either come up with another way to pay for the newly eligible or else dramatically shrink their program.

“I have deep concerns with details in the U.S. Senate’s plan to fix America’s healthcare system and the resources needed to help our most vulnerable, including those who are dealing with drug addiction, mental illness and chronic health problems and have nowhere else to turn,” said Kasich, who has been a vocal critic of Republican efforts to repeal and replace the ACA.

(Peter Stevenson/The Washington Post)

The consequences of the new legislation would be dramatic in Ohio, where more than 600,000 of those on Medicaid last year gained access to care as a result of that state’s decision to broaden the program, according to the Kaiser Family Foundation.

Sandoval took a sharper tone in a statement issued Thursday in which he criticized Senate leaders for crafting their bill behind closed doors.

“I am disappointed that Congress did not include us in the consideration of this bill and we have not seen it until today,” he said. “While the current healthcare system needs improvement, it remains my priority to protect Nevada’s expansion population to ensure our most vulnerable, especially individuals with mental illness, the drug addicted, chronically ill, and our children, will always have access to healthcare.”

More than 200,000 Medicaid recipients in Nevada last year — more than a third of its entire Medicaid population — were eligible for coverage because of the expansion. Sandoval reiterated his objections Friday during a joint news conference with Sen. Dean Heller (R), a key swing vote on the bill, who announced that he could not support it as written.

Hogan also focused on how GOP leaders on Capitol Hill had operated in drafting their measures. “Congress should go back to the drawing board in an open, transparent and bipartisan fashion to craft a bill that works for all Americans,” he said through a spokeswoman.

But at least one Republican governor of an expansion state signaled that he felt the bill was a step in the right direction. Gov. Asa Hutchinson of Arkansas said in a statement that more time was needed to gauge the measure’s potential impact but that “there are significant positive changes in the Senate bill, including increased flexibility for the states.”

The expansion population in Arkansas topped 300,000 last year, according to Kaiser. Hutchinson is seeking permission from the Trump administration to make conservative adjustments to the program there, including instituting a work requirement for many enrollees.

Other GOP governors of expansion states were silent or issued statements saying they needed time to study the legislation’s specifics.

Earlier this month, Kasich, Sandoval and Baker joined several Democratic governors to pen a letter to congressional leaders urging them to scrap the health-care bill the House passed last month in favor of something that would garner bipartisan support. No Democrats are expected to support either the House or Senate versions.

This week, that trio noted their particular concern about the Senate bill’s impact on their efforts to combat the opioid epidemic. Ohio is among the states hardest hit by the crisis. In 2016, the expansion accounted for 43 percent of Ohio’s Medicaid spending on behavioral health, a category that includes substance abuse treatment, according to the Associated Press.

Nationwide, nearly 1.3 million people receive services for mental-health and substance abuse disorders under the Medicaid expansion, according to an estimate by economists Richard G. Frank of the Harvard Medical School and Sherry Glied of New York University.

In recognition of the challenges states face on this issue, the Senate bill would create a $2 billion fund to provide grants to states for substance abuse and mental health treatment.

The House and Senate bills would make radical, longer-term changes to Medicaid. Since its inception more than 50 years ago, the program has been funded as an entitlement for anyone who qualifies. Under both congressional measures, states would instead receive a per capita amount or block grant from the federal government.