Why GOP governors like Medicaid under Obamacare. Hint: $

Some Trump supporters hoping they don't lose Obamacare
Some Trump supporters hoping they don't lose Obamacare

The rush to repeal Obamacare on Capitol Hill is running into resistance in some state capitals.

Some Republican governors who have expanded Medicaid, along with their Democratic peers, don't want Congress to kill the provision that has allowed 11.3 million low-income adults nationwide to gain health care coverage.

Several GOP governors met with the Senate Finance Committee on Thursday to discuss the future of Medicaid and the Affordable Care Act. Also, House Majority Leader Kevin McCarthy has asked all governors to submit the changes they'd like made to Medicaid and Obamacare.

The Republican governors' views vary. Of the 31 states, plus the District of Columbia, that have broadened Medicaid eligibility, 16 are run by GOP governors.

Kasich, one of the early GOP governors to embrace expansion, defended portions of the Affordable Care Act on Thursday. He noted that people, particularly those with pre-existing conditions, want to make sure they don't lose their coverage.

"The whole key to it is for people to be able to get some degree [of] help in terms of purchasing health insurance," said Kasich, while discussing the Republican plan to provide tax credits to help enrollees afford insurance. "You just have to make sure the tax credit is generous enough to give people primary coverage."

In their letters to McCarthy, none of the state chief executives call for eliminating Medicaid expansion and some who lead states that have expanded Medicaid acknowledge its importance, said Jocelyn Guyer, managing director at consulting firm Manatt Health Solutions, who reviewed many of the governors' written responses to McCarthy.

Related: Major changes for Medicaid coming under Trump and the GOP

More conservative Republican governors blast Obamacare for the federal mandates and higher costs, while more moderate ones call for improvements to existing regulations.

All, however, are interested in gaining more control over Medicaid, so they can tailor their programs and institute new rules -- such as work requirements and higher premiums and co-pays. But only a few call for capping federal payments to cover their low-income population.

Republicans lawmakers in Congress remain fractured over how to dismantle the law, but most of their key proposals so far involve rolling back Medicaid expansion and putting a limit on federal funding for the entire program.

Governors, however, are extremely invested in Medicaid since it's the largest source of federal funding for states, said Joan Alker, executive director of the Center for Children and Families at Georgetown University. If Medicaid is restructured, it will ripple through states' budgets and could affect spending on other programs, such as education.

Under Obamacare, adults with incomes of up to 138% of the poverty line -- $16,400 for a single person -- are allowed to sign up for Medicaid in states that expanded their programs.

Medicaid expansion has meant even more money for participating states since the program began in 2014. The federal government, which covered 100% of the cost of newly eligible adults for the first three years and is slowly tapering that reimbursement to 90%, pumped an additional $72.6 billion into the expansion states last year.

"It's gotten baked into the state budgets," said Guyer.

Nearly 73 million Americans, mainly low-income children and parents, pregnant women, the disabled and the elderly, are on Medicaid or the related Children's Health Insurance Program (CHIP). The programs cost $532 billion in fiscal 2015, with the federal government shouldering 63% of the bill and states paying 37%.

Massachusetts Governor Charles Baker, for instance, pointed out that his state's Medicaid and CHIP programs provide coverage for nearly 1.9 million residents, with 300,000 of them newly eligible under expansion.

"[Medicaid] is an important safety net for a significant portion of our state's population," said Baker, a moderate Republican. "Proposals that suggest states may be provided with more flexibility and control must not result in substantial and destabilizing cost shift to states."

Related: Trump HHS nominee: It's 'imperative' people be able to keep health coverage

In Nevada, Medicaid expansion and the Affordable Care Act have "allowed thousands of Nevadans needing mental health treatment to receive care," wrote GOP Governor Brian Sandoval.

Some of these governors agree with their GOP peers in non-expansion states that they should have more flexibility over what benefits to offer poor residents and what requirements to impose on them. Currently, few states make recipients pay for care, while the Obama administration has rejected state requests for a work requirement.

Governor Gary Herbert of Utah, which did not expand, asked Congress to give states the ability to institute "meaningful premiums and copays" -- which usually means a state can kick participants out of the program if they don't pay -- for parents and childless adults and to limit enrollment if costs exceed the budget.

Florida Governor Rick Scott, who noted that he's discussed health care with President-elect Trump and Vice President-elect Mike Pence, wants more flexibility to run his state's program.

"I have a better idea of needs in my state," he said Thursday. "Let me figure out how to take care of those individuals."

When it comes to funding, Republican governors are more cautious about turning Medicaid into a block grant program that would send a fixed amount of federal funds to the states, a tool of choice for Congressional Republicans.

Some agree with left-leaning governors and experts that block grants could reduce the effectiveness of the safety net. Meanwhile, leaders of non-expansion states are concerned that funding might be frozen at current levels, which would leave them at a disadvantage since they did not broaden their programs.

Related: Repealing Obamacare affects everyone

Still, a few governors were supportive of block grants.

"A Medicaid block grant will allow us to cover those who are truly in need while helping those who are able to transition from government dependence to true independence through hard work," said Wisconsin Governor Scott Walker.

Not surprisingly, Democratic governors praised Obamacare and Medicaid expansion in their letters to McCarthy, saying it has helped their states lower their uninsured rates, created jobs and lowered the level of uncompensated care.

Washington Governor Jay Inslee wrote that his state's uninsured rate has dropped to an unprecedented 5.8%, from 14%, and nearly 600,000 people have gained coverage through Medicaid expansion.

"Any attempt to roll back the ACA is a roll back on one of the most important things we've done to help working families in recent years," Inslee wrote.

Editor's Note: This story originally noted that Medicaid cost $509 billion for the fiscal year ending June 30, 2015. It's been updated to reflect the data for federal fiscal year 2015, which ended Sept. 30, 2015.

CNN's MJ Lee and Tom LoBianco contributed to this story.

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