While Republicans in Congress work overtime to repeal Obamacare, Republicans in statehouses are actually working to expand it.

Republican legislators in multiple states have introduced bills and supported ballot initiatives to expand Medicaid, the public program that covers low-income Americans. If the efforts succeed — and they’ve demonstrated early victories in recent weeks — Obamacare enrollment would increase by an estimated 200,000 people.

“I feel so strongly it’s the right thing to do,” says Susan Concannon, a Kansas Republican state legislator. “We have citizens who are uninsured and hospitals that are suffering.”

Thirty-one states currently participate in Medicaid expansion, including 15 led by Republican governors. The program covers millions of Americans and has become one of the most challenging parts of the law to dismantle. Rep. Greg Walden (R-OR), who chairs one of the committees tasked with writing the replacement bill, recently told reporters that the draft was nearly done — except for the part that figures out what to do with Medicaid expansion.

Medicaid expansion has split the Republican Party between those who see it as a crucial safety net for low-income Americans and those who see it as another expansion of a costly entitlement program that states don’t have the budget to fund.

“I don’t think we have the resources to get it done,” Kansas Gov. Sam Brownback said in late 2016 of the Medicaid expansion.

What makes repealing Medicaid hard is that so many Americans now rely on the program, even in conservative states. And if Maine or Kansas expands the program, the challenge would only grow as tens of thousands more Americans signed up.

“What I thought was going to be easy was, I thought, Medicaid: We’d just block-grant it to the states,” says Rep. Phil Roe (R-TN). “That one actually is going to be a little harder than I thought. The reason is there are states like New York, states that expanded [Medicaid]. How do you cover that 10 or so million people on Medicaid?”

Republican legislators in Maine, Kansas plot Medicaid push

Republican legislators in both Maine and Kansas have spent years now pushing to expand Medicaid. Just as Obamacare is on the brink of repeal, they are starting to see results.

Concannon, the Kansas state legislator, repeatedly introduced a Medicaid expansion bill. In late February, the proposal passed the Kansas House for the first time. It was overwhelming: 81 voted in favor, and 44 against.

She did not like Obamacare when it passed, but over time her views have changed. “I was furious with the way it was pushed through,” she recalls. “I’m not an activist or supporter now, but I can see when things are working.”

She sees Medicaid expansion as clearly working in other states. Insured rates in some states that expanded Medicaid, such as Kentucky and Arkansas, have gone up 12 percentage points between 2013 and 2015.

Kansas has not expanded Medicaid, and the state’s insured rate has barely budged, rising only 1.5 percentage points over the same time period.

Maine state Sen. Tom Saviello, a Republican, sees Medicaid expansion similarly. The district he represents has a 15 percent uninsured rate, much higher than the national average.

He has repeatedly introduced bills to expand Medicaid that have failed, sometimes by just a single vote.

“I represent one of Maine’s poorest counties, and I see a lot of people that don’t have health insurance,” he says. “My own party is mad at me because I continue to pursue it, but we have to do something. I look at Franklin County, which I represent, and roughly 1,000 people would gain coverage there.

“The people I represent need this,” he continues. “It’s as simple as that.”

Saviello is now supporting a new effort to expand Medicaid in Maine: a ballot initiative that wouldn’t need the support of the legislature or governor. It easily collected the 70,000 signatures it needed to land on the Maine ballot late last year, and in late February, the state certified it had made the 2017 ballot (unless lawmakers decide to pass an unaltered version of the bill first).

“We thought we’d start collecting signatures on Election Day and continue through the year and be on the 2018 ballot,” says Robyn Merrill, a spokesperson for Mainers for Healthcare, the group backing the effort. “The fact that we already have 70,000 signatures and are on the 2017 ballot tells you something.”

More Medicaid expansion could be a headache for repeal efforts

Medicaid expansion has a surprisingly robust and active support base on Capitol Hill, in part because it enjoys the support of some prominent Republican governors.

"That is a very, very bad idea, because we cannot turn our back on the most vulnerable," Ohio Gov. John Kasich told CNN in a February 19 interview about the idea of repeal.

Gov. Rick Snyder of Michigan said, in January, “I hope they carefully look at the success we’ve had in Michigan.”

Medicare usually that proves difficult to cut because its beneficiaries are seniors, and they vote in large numbers. By contrast, low-income Americans have lower turnout, and that makes the programs they rely on more vulnerable.

What’s different about Medicaid expansion? To start, the program has consistently had higher-than-expected enrollment. Last March, the Congressional Budget Office increased its projection for Medicaid expansion enrollment from 14 million to 18 million.

Higher enrollment numbers make the program harder to end, as it would mean kicking millions more patients off the rolls.

Medicaid expansion is also a huge boon to hospitals, who provide less charity care when more patients have coverage. Because hospitals are large employers and strong lobbyists, this also makes politics of rolling back Medicaid expansion tricky.

“The governors will be held responsible when community health centers report large deficits or rural hospitals say they have all these unpaid bills,” says Robert Blendon, a professor of health policy and political analysis at the Harvard Kennedy School of Government. “A lot of local things will be attributed to the governor, just like the economy going badly.”

If Kansas and Maine add themselves to the list of expansion states, it will only compound the struggle to repeal the law — by adding nearly a quarter-million more Americans to the Obamacare rolls.

Roadblocks to Medicaid expansion still exist — and they’re big

In Kansas, Concannon’s Medicaid expansion bill still faces significant hurdles to becoming law.

It needs to move through the Kansas Senate and, if it does, will near certainly be vetoed by Gov. Brownback, a Republican and staunch Medicaid expansion opponent. This means the Kansas legislature would need enough support for a veto override: 84 votes in the 125-member House and 27 votes in the 40-member Senate.

Brownback is among the 17 Republican governors who run states that have not expanded Medicaid — so is Maine’s governor, Paul LePage. Both worry that the program would prove too expensive for their state.

“The expansion offered through Obamacare would have a disastrous impact on Maine’s budget,” LePage said in a statement when he vetoed a 2014 Medicaid expansion bill that Saviello introduced.

Independent analysis from the consulting firm Manatt estimates that Maine would end up with $26.7 million in additional revenue should it expand Medicaid in 2016, even accounting for the spending it would need to do on the program.

Saviello hopes the ballot initiative passes. And, if not, he plans to keep introducing bills. “I’m like Don Quixote,” he says. “I just keep chasing the windmills.”

Concannon realizes that Brownback will reject her bill if it ever crosses his desk. She says some of the other Republicans in the caucus are angry at her because she keeps pushing the issue.

But, she asks, what else is she supposed to do? “I know we have a governor for two more years who will veto this,” she says. “But I don’t think I can be paralyzed by fear of what might happen, and not do anything about it.”