Republicans eye ACA money while still seeking alternatives

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WASHINGTON -- In the bitterly partisan debate over the Affordable Care Act, few House members criticized the proposed legislation as harshly or as often as then-Rep. Mike Pence. But now, nearly four years after the measure passed on a party-line vote, Mr. Pence, now Indiana's governor, is asking the federal government for ACA money to expand a program that provides coverage to low-income Hoosiers.

But he wants to do it outside the confines of the health care law.

Mr. Pence is among a small but growing number of Republican governors and lawmakers looking for alternatives to expanding Medicaid. They don't want to be seen embracing a law almost universally loathed in their party, but the hundreds of millions of dollars available to their states through the law's provisions are too enticing to pass up.

"Obamacare was a mistake. It was, to borrow a phrase, a bad idea poorly executed," Mr. Pence said in an interview. "But where I work, it's about solutions. People are looking for results."

On Friday, Mr. Pence met with Kathleen Sebelius, Health and Human Services secretary, to ask for a waiver for the Healthy Indiana Plan, which helps about 45,000 low-income residents with personal health funds linked to insurance plans with high deductibles. Mr. Pence wants to use the federal money earmarked for Indiana's Medicaid expansion to grow that program instead.

"We're currently in negotiations with the administration about using the resources that are available for Medicaid expansion to expand the Healthy Indiana Plan," he said.

GOP governors in other states are using the same technique, seeking waivers to use Medicaid expansion money to fund alternative programs that would accomplish many of the same goals, but under a different name.

"There's a lot of trying to say they're not doing Obamacare, so that they can call it something different," said Diane Rowland, a Kaiser Family Foundation executive vice president and health policy expert. "They're trying to put some distance between the straight concept of a Medicaid expansion, so they can build a coalition in the legislature."

Pennsylvania's Republican Gov. Tom Corbett has sought a waiver to include work requirements in Medicaid expansion, while Utah's Republican Gov. Gary Herbert last month said he will push to expand Medicaid in some form during this year's legislative session.

Wisconsin's Republican Gov. Scott Walker has performed his own version of this political jujitsu: His state has curtailed Medicaid to the point where it covers only those who make up to 100 percent of the federal poverty level -- $23,550 for a family of four. Those who earn more and who don't have dependent children are covered under BadgerCare, a program that received Medicaid expansion money.

In New Hampshire, the state Senate has agreed on a plan that ultimately will use federal Medicaid money to pay for private insurance for those newly eligible for Medicaid. Arkansas legislators are trying to pass a similar measure that would use the Medicaid money to fund what they call the "private option." State law requires three-quarters of both legislative chambers to approve any appropriation; the private option has passed the Republican-controlled Senate and remains just two votes short of passing the GOP-led House.

Arkansas' Democratic Gov. Mike Beebe said several governors from states that have not expanded Medicaid have approached him to learn more about the private option. The word "private" is a cover in states where anything associated with President Barack Obama's signature domestic policy achievement would be politically unpalatable.

Even if the differences between an alternative state program and traditional Medicaid are cosmetic, being able to say a state has requested a waiver can be a political benefit. "A waiver makes it sound like they've negotiated something different and gotten a better deal," said the Kaiser Foundation's Ms. Rowland. "Most of the states that are on the fence or negotiating waivers are trying to expand Medicaid."

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