Todd Spangler

Detroit Free Press

WASHINGTON — Gov. Rick Snyder, Ohio Gov. John Kasich and two other Republican governors have added their voices to the chorus of opposition to House Speaker Paul Ryan's proposal to replace the Affordable Care Act, saying it fails to give them the flexibility or resources they need to adequately deal with the insurance needs of lower-income Americans.

Saying they had been "encouraged" by statements made by President Donald Trump that he would work with the governors to help address the "diverse needs" of Medicaid recipients, the governors — a group that also included Asa Hutchinson of Arkansas and Brian Sandoval of Nevada — said the bill, endorsed by Trump, "does not meet this test."

"It provides almost no new flexibility to the states, does not ensure the resources necessary to ensure no one is left out and shifts significant costs to states," the governors wrote in a letter sent to Ryan, R-Wis., and Senate Majority Leader Mitch McConnell, R-Ky. "We stand ready to work with you to develop a proposal that is both fiscally sound and provides affordable coverage for our most vulnerable citizens."

Snyder had been largely silent since Ryan early last week revealed his proposal for replacing the Affordable Care Act, otherwise known as Obamacare. The proposal calls for limiting Medicaid expansion authorized by the ACA and enacted in 31 states, including those of the four governors signing the letter. The new plan calls for cutting back on the amount of funding they would receive for new recipients past 2020.

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The expansion allowed states to cover recipients earning up to 133% of the federal poverty level with an additional funding match from the federal government. Michigan's Medicaid expansion program, called Healthy Michigan, has signed up more than 650,000 residents. Across the four states, more than 2 million people have been covered by expansion programs.

While Snyder and the other governors haven't been precise on what they mean by "flexibility," it's been clear for some months that if the ACA were to be repealed and replaced, they hoped to get special consideration for their Medicaid expansion programs continuing. In his State of the State speech early this year, Snyder said it was "important" to show Congress and the White House "that Healthy Michigan is a model that can work for the rest of the country."

Snyder — while declining to speak specifically on what he's asked the federal government for in terms of the program — has touted the fact that it reduces costs to recipients if they adopt more healthy behaviors, promotes Health Savings Accounts to defray medical costs and cuts down on the number of lower-income Michiganders seeking care without insurance. He has also made clear his belief that by encouraging healthy behavior and preventive care, hospital visits — and costs — can be reduced.

Continuing Healthy Michigan, however, could require substantial federal help, given the state's finances.

Earlier this year, Snyder and other Republican governors had praised members of Congress and the Trump administration for meeting with them to consider their concerns that whatever a replacement for the ACA looked like, it needed to give them the resources and flexibility needed to continue to insure low-income individuals and families in their states that got coverage under the program.

Republicans have been calling for the ACA's repeal since it was approved in 2010 and with Trump winning the White House and Republicans controlling both chambers of Congress, there is pressure to replace the health care reform law, especially with premiums for people buying insurance on the state exchanges going up significantly in many places this year and the number of insurers offering policies — many aspects of which are set by law — declining in some places.

Ryan's replacement proposal for Obamacare —- which also calls for phasing out subsidies for individual insurance and replacing them with flat tax credits based on age, as well as giving insurers greater flexibility to write policies and charge older Americans up to five times that charged younger ones — has run into severe headwinds, not only from Democrats but also from conservative Republicans who say it continues a program that should be stopped altogether.

The key committees considering Ryan's bill have already signed off on it but it's not yet clear what the amendment process will be, though media reports said the speaker plans to bring it to the floor of the U.S. House for a vote next Thursday. Even if it does pass the House, however, it is expected to have a difficult time passing in the Senate without major revisions.

Contact Todd Spangler: 703-854-8947 or at tspangler@freepress.com. Follow him on Twitter at @tsspangler.