Republican governors who reaped the benefits of Obamacare now find themselves in an untenable position — fighting GOP lawmakers in Washington to protect their states’ health coverage.

This rift between state and federal GOP officials is the real battle on Obamacare at a time when Democrats have only marginal power in Congress. The voices of even a handful of Republican governors intent on protecting those at risk of losing coverage could help shape an Obamacare replacement and soften the impact on the millions who depend on the law.


President-elect Donald Trump heaped more pressure on lawmakers to find a resolution of the issue this week when he vowed to “repeal and replace Obamacare essentially simultaneously” after the Senate confirms Rep. Tom Price, his pick for Health and Human Services secretary.

But Trump’s push comes as at least five of the 16 Republican governors of states that took federal money to expand Medicaid are advocating to keep it or warning GOP leaders of disastrous consequences if the law is repealed without a replacement that keeps millions of people covered. They include Govs. Charlie Baker of Massachusetts, Rick Snyderof Michigan, John Kasichof Ohio, Asa Hutchinson of Arkansas and Brian Sandovalof Nevada.

And more Republican governors might join with a Friday deadline to submit written proposals to Republican leadership on the Hill.

If anyone could sway congressional Republicans, it’s these officials who are closest to the millions affected and more likely to be in the direct line of fire, said several former state and federal health officials. Members of Congress have close working relationships with state leaders and are also representatives and taxpayers, said Tommy Thompson, a former Wisconsin governor and HHS secretary under George W. Bush.

“They will have a much more or a substantial influence on things like Medicaid,” said Thompson, who met with Trump in December to discuss Obamacare.

There are signs they are getting a hearing, at least: In the House, GOP lawmakers are speaking with four or five expansion-state governors to see if they can find ways to address their concerns, said Rep. Chris Collins, a New York Republican acting as a liaison between the House and the incoming Trump administration.

Gov. Rick Snyder is one of five Republican governors of states that took federal money to expand Medicaid who are now advocating to keep it or warning against the consequences of repealing Obamacare. | Getty

“We don’t want to leave them hung out to dry on the expansion,” Collins said.

Senate Finance Committee Republicans, meanwhile, are hosting a meeting with Republican governors next Thursday to discuss Medicaid.

While many pro-expansion GOP governors seek greater state flexibility to manage health programs as did their non-expansion state counterparts, they went out on a political limb to take federal money to expand Medicaid. If that money stops flowing and tens of thousands of residents lose coverage, they face huge political and budgetary challenges. Sixteen of the 31 states that expanded Medicaid are led by Republicans.

“We are now able to provide health insurance to 700,000 people,” said Kasich, who circumvented his state Legislature to enact expansion in 2013 and who was the sole GOP presidential candidate in 2016 to defend that portion of Obamacare.

“Let’s just say they just got rid of it, didn’t replace it with anything,” he said. “What happens to the 700,000 people? What happens to drug treatment? What happens to mental health counseling? What happens to these people who have very high cholesterol and are victims from a heart attack? What happens to them?”

Arkansas’ Hutchinson told House GOP leaders Wednesday that he wants to keep Obamacare’s federal funding boost for expanded Medicaid — but have more flexibility to run the program as he’d like.

Michigan’s Snyder says he defended his state’s Medicaid expansion to Trump’s team and the state’s congressional delegation.

"Massachusetts believes strongly in health care coverage for its residents," Baker wrote in a letter to House Republican leadership on Wednesday.

And Nevada's Sandoval, in a letter that outlined at great length how Obamacare has benefited his state, warned Republicans about gutting the law.

“You must ensure that individuals, families, children, aged, blind, disabled and mentally ill are not suddenly left without the care they need to live healthy, productive lives,” Sandoval said.

Before Obamacare, Medicaid was a program that mostly covered low-income children, pregnant women and the disabled. The health care law expanded eligibility to adults with incomes up to 138 percent of the federal poverty line, or about $16,400 for an individual. For the first time in many states, single able-bodied adults were able to get coverage.

Conservatives railed against it as an unsustainable expansion of the safety net — concerns that were magnified because the federal government covered the entire cost for the first three years.

Still, many Republican governors took the cash, saying it would benefit their citizens, hospitals and budgets. That includes Vice President-elect Mike Pence, who as Indiana governor enacted a Medicaid expansion model with some conservative tweaks, like requiring beneficiaries to pay into health-savings accounts.

Big splits remain between the leaders of pro- and anti-expansion states, which are stymieing efforts to deliver a clear message to lawmakers in D.C.

“There’s no unanimity so far,” said one Republican lobbyist. “Right now, it’s just everyone for themselves.”

Thompson said he believes Republicans are intent on transforming Medicaid from an entitlement into a block grant, which would cap the federal government’s payments and give them greater flexibility in how they spend the money. Many Republican governors say they support such an approach, including Pence, Hutchinson and Kentucky Gov. Matt Bevin, who inherited expanded Medicaid eligibility from his Democratic predecessor.

But others oppose that model, saying that it would likely eliminate the guarantee that everyone who’s eligible could get benefits. Baker, for instance, told House Republicans that any changes to Obamacare must weigh the impact on Medicaid because it is “an important safety net.”

The Massachusetts governor also argued against shifting more costs to states.

There’s also likely to be state infighting about how Congress sets future Medicaid funding levels if it decides to cap the federal government's investment, Thompson said. The states that expanded under Obamacare could receive more funding than those that didn’t.

“All of this is going to add into a real fight,” he said. “Until they get to that end result, there’s going to be a lot of sharp elbows.”

Josh Dawsey contributed to this report.