WASHINGTON -- John Thune of South Dakota, the No. 3 Republican in the Senate, voted earlier this month to repeal major provisions of the Affordable Care Act and to end its expansion of Medicaid, arguing that the health law was "unpopular and unaffordable."
A week later, his state's Republican governor, Dennis Daugaard, announced that he wanted to make 55,000 additional South Dakota residents eligible for Medicaid under the law.
"I know many South Dakotans are skeptical about expanding Medicaid, and I share some of those sentiments," Daugaard said. "It bothers me that some people who can work will become more dependent on government."
"But," Daugaard said, "we also have to remember those who would benefit, such as the single mother of three who simply cannot work enough hours to exceed the poverty line for her family."
In state after state, a gulf is opening between Republican governors willing to expand Medicaid coverage through the Affordable Care Act and Republican members of Congress convinced the law is collapsing and determined to help it fail. In recent months, insurers have increased premiums and deductibles for many policies sold online, and a dozen nonprofit insurance co-ops are shutting down, forcing consumers to seek other coverage.
But in Arizona, Arkansas, Indiana, Iowa, Michigan, New Jersey, Nevada and Ohio, Republican governors have expanded Medicaid under the health care law or defended past expansions. In South Dakota, Tennessee and Utah, Republican governors are pressing for wider Medicaid coverage. And Republican governors in a few other states, including Alabama, have indicated that they are looking anew at their options after rejecting the idea in the past.
That has created tension with Washington that some lawmakers can no longer ignore.
"I am very reluctant to take positions that counter the decisions made by the governor," said Sen. John McCain, R-Ariz., where more than 78,000 people have gained Medicaid coverage under legislation signed in 2013 by Jan Brewer, a Republican who was then the governor. Now, Gov. Doug Ducey, also a Republican, is seeking a federal waiver to charge premiums and co-payments and create work incentives within the limits allowed by federal rules.
"The governor and Legislature in my state decided that they wanted" to expand Medicaid, McCain said.
Joan C. Alker, a senior researcher at the Health Policy Institute of Georgetown University, said the divide was "a reflection of the larger fight in the Republican Party between more pragmatic Republicans, including governors, and the ideological wing of the party that wants to stop Obamacare at all costs."
Tarren Bragdon, chief executive of the conservative Foundation for Government Accountability, said that to governors of both parties, federal funds looked like "free money." By contrast, he said, Republicans in Congress focus on costs to the federal government and believe that the expansion of Medicaid will not be sustainable or affordable in the long term.
When Democrats wrote the Affordable Care Act, they wanted to make Medicaid available to all Americans under 65 with incomes up to 138 percent of the poverty level — or $16,240 for an individual. The federal government pays the full cost for newly eligible beneficiaries from 2014 to 2016 and at least 90 percent after that.
In 2012, the Supreme Court ruled that the expansion of Medicaid was an option for states, not a requirement. Thirty states have chosen to expand eligibility, and several others are negotiating with the Obama administration. But state-level brawls over Medicaid expansion have mirrored the wider political war over the law.
Gov. Bill Haslam of Tennessee, a Republican, wanted to use federal Medicaid money to extend coverage to 280,000 low-income people. His proposal failed in the spring in the Legislature, under attack by conservative groups like the Koch brothers' Americans for Prosperity, which urged voters to "stop Obamacare in Tennessee."
No member of Congress has attacked the Affordable Care Act with more zeal than Sen. John Barrasso, R-Wyo. But Gov. Matt Mead of Wyoming, also a Republican, is urging state legislators to expand Medicaid to cover thousands of low-income people.
"When I came into office in 2011, I joined other states in a lawsuit challenging the Affordable Care Act, and I still don't like it," Mead said in an interview. "But it's the law of land. So now I'm trying to be pragmatic, recognizing that we have about 18,000 people who could obtain coverage. We have small hospitals that are struggling. Our federal tax dollars are not headed back to Wyoming, but are paying for health care in Colorado, California and other states."
Clinching the case for Mead is the state's fiscal plight. Revenue is down because of a steep decline in oil and natural gas prices. With the expansion of Medicaid, he said, Wyoming would receive an infusion of federal funds, easing its budget problems.
In Arkansas, a centrist Democratic governor, Mike Beebe, found a novel way to expand Medicaid in 2013, using federal money to buy private coverage for 220,000 low-income people through the insurance exchange set up under the health care law. His successor, Gov. Asa Hutchinson, a Republican, said this month that he wanted to continue the expansion while adding some conservative features, including premiums and work incentives.
"I opposed and continue to oppose the Affordable Care Act," Hutchinson said. But, he added, "we're a compassionate state, and we're not going to leave 220,000 people without some recourse."
Ray Hanley, a former director of the Medicaid program in Arkansas, summarized the prevailing sentiment this way: "We hate Obamacare and would repeal it tomorrow if we could, but we can't. So we must do what is best for Arkansas."
In Utah, Gov. Gary R. Herbert, a Republican, has been trying for two years to expand Medicaid in some way that would be acceptable to state legislators and federal health officials.
Sen. Orrin G. Hatch, R-Utah, chairman of the Finance Committee, has stayed out of the negotiations, but aides said he thought the expansion of Medicaid under the health law was a terrible idea. His Republican colleague from Utah, Sen. Mike Lee, said, "Medicaid's abysmal track record of failing our most vulnerable populations will only get worse as millions of new, able-bodied adults join the program."
To the authors of the law, Republican intransigence in Washington is baffling. The Senate Democratic leader, Harry Reid of Nevada, said Republicans in Congress "aren't listening to their constituents or state leaders." The Republican governor of his state, Brian Sandoval, expanded Medicaid and remains highly popular.
To this day, many Republicans on Capitol Hill are upset about the way the Affordable Care Act was adopted in 2010 — rammed through Congress, they say, without any Republican votes and with scant regard for their concerns.
Sen. Lamar Alexander, R-Tenn., said he remembered discussing health care with President Barack Obama in early 2010, but, he said, the president and congressional Democrats "didn't take any of my advice and hardly any of the advice of my Republican colleagues about what the disastrous outcomes of Obamacare would be." Medicaid accounts for 30 percent of Tennessee's budget, he said, and expanding eligibility means "having less to spend on other priorities like higher education, roads and schools."
In swing states like Ohio, the politics of Medicaid have become challenging.
More than 600,000 Ohio residents have gained coverage under Medicaid since Gov. John R. Kasich expanded eligibility. In his bid for the Republican presidential nomination, Kasich has come under criticism from conservatives but has defended his action, saying he felt a moral imperative to help the poor.
Sen. Rob Portman of Ohio is running his first Senate re-election campaign, in the heat of a presidential election year. He voted with other Republicans to repeal the federal health care law but is cautious in his criticism.
"Medicaid badly needs reform," Portman said. But, he added, "we must ensure that Ohioans who rely on it for health care don't have a lapse of coverage.