Republican Arizona Gov. Jan Brewer, who has been one of the most outspoken foes of President Barack Obama's health care overhaul (and who famously jabbed a finger toward the president during a tense verbal exchange last year), surprised her GOP colleagues three weeks ago when she backed the expansion of her state's Medicaid program.
That makes her the fourth Republican governor, and the 23rd governor overall, to call for such an expansion.
Will Pennsylvania -- controlled by the GOP in both legislative chambers, with Republican Gov. Tom Corbett at the helm -- be next?
The Medicaid expansion is one of the key provisions of the 2010 Affordable Care Act, dubbed "Obamacare" by critics. When the expansion takes effect, it will allow the state-run health insurance program for the poor to cover residents earning 138 percent of the federal poverty level. The federal government will pick up most of the tab for this added coverage -- in fact, it will pay the full cost for the first three years, and 90 percent in the long-term -- and that up-front cash is one of the reasons Arizona's governor signed on.
Nevada's signed on, too, as did New Mexico and North Dakota, all controlled by Republican governors.
So far, Mr. Corbett has shown no signs that he will, but neither has he suggested that he will slam the door completely this week, when he unveils his proposed budget. If Mr. Corbett intends to expand Medicaid eligibility in 2014, he may account for it in his 2013-14 budget -- or he may hold back and use the Medicaid expansion as a bargaining chit during budget negotiations.
Mr. Corbett faces pressure from not only minority Democrats, but also advocates for the poor, the politically powerful AARP, and hospital networks.
"We have supported Medicaid expansion and continue to do so," said Roger Baumgarten, spokesman for the The Hospital & Healthsystem Association of Pennsylvania, partly because uninsured and underinsured patients still use hospital emergency rooms, forcing Pennsylvania hospitals absorb nearly $1 billion a year in unreimbursed costs.
Foes of expansion include Republicans such as state Reps. Tim Krieger, Stephen Bloom, Matt Gabler and House Majority Whip Stan Saylor, who have scheduled a Monday press conference, urging the governor to spike the Medicaid deal because of its "destructive impacts."
"It's daunting," Mr. Krieger, R-Westmoreland, said last week. "Just from 2000 to 2012, Medicaid expenditures have doubled," and with 1 in 6 Americans already enrolled in Medicaid, growth in the program isn't sustainable, he said.
As far as smoke signals go, a spokesman for the state Department of Welfare has said the state is examining the issue but "cannot ignore the $4.1 billion in state-only taxpayer costs over the next eight years that could occur as a result of expanding Medicaid in Pennsylvania," according to The Philadelphia Inquirer.
Other groups have arrived at more modest calculations. The Kaiser Commission on Medicaid and the Uninsured, for example, estimates that 719,000 additional Pennsylvanians would enroll in Medicaid by 2022, if Mr. Corbett were to expand Pennsylvania's program, allowing it to accept people and families making up to 138 percent of the poverty level.
Kaiser says Pennsylvania's in-house Medicaid costs will come to an extra $2 billion through 2022, not $4 billion.
Either way, it's a crucial decision for the governor, and for the rest of his undecided counterparts (11 states have already said they won't take the money and won't expand Medicaid eligibility, according to The Associated Press).
Mr. Corbett and Ms. Brewer were among the Republican governors who sued to overturn the 2010 health care law. While most of the law was declared constitutional by the U.S. Supreme Court, the provision of the law that made the Medicaid expansion effectively mandatory was struck down, giving the states discretion when it comes to the expansion.
If all the states would agree to the expansion, an estimated 21 million uninsured people would soon be receiving health insurance.
"It's the biggest expansion of Medicaid in a long time, and the biggest ever in terms of adults covered," said Mark McClellan, who ran Medicare and Medicaid when Republican George W. Bush was president. Medicaid generally pays for health insurance for low-income families, their children, people with certain disabilities and seniors in nursing care homes -- but often poor, individual adults are not eligible, something the expansion hopes to remedy.
"Although the federal government is on the hook for most of the cost, Medicaid on the whole is one of the biggest items in state budgets and the fastest growing. So there are some understandable concerns about the financial implications and how implementation would work," Mr. McClellan said.
A major worry for states is that the deficit-burdened federal government sooner or later will renege on the 90 percent deal. The regular Medicaid match rate averages closer to 50 percent, which would represent a significant cost shift to the states.
Many Republicans also are unwilling to keep expanding government programs, particularly one as complicated as Medicaid, which has a reputation for being inefficient and unwieldy.
The health care law will go into full effect next Jan. 1, and states are scrambling to crunch the numbers and understand the Medicaid trade-offs.
States can refuse the expansion outright or indefinitely postpone a decision. But if states think they'll ultimately end up taking the deal, there's a big incentive to act now: The three years of full federal funding for newly eligible enrollees are only available from 2014 through '16.
Bill Toland: firstname.lastname@example.org or 412-263-2625. The Associated Press contributed.