Partisan politics are coloring governors' decisions about whether to expand Medicaid in their states, affecting billions of dollars and thousands of low-income people.
The question of whether they receive Medicaid coverage may have little to do with need, and much to do with the way their states vote in governors' races, including primaries.
Every Democratic governor has called for accepting larger-than-usual federal subsidies to expand Medicaid, the government health insurance program for the poor. The only three who failed were blocked by Republican state legislators.
Most of the 30 Republican governors have turned down Medicaid expansion, and the federal dollars that would come with it. Some who face potential tea party challengers in next year's GOP primaries have rejected advice to broaden the program, which they call a costly federal overreach.
But a few Republican governors dismiss those arguments. They have accepted billions in federal money to cover more people with Medicaid. It would shortchange their constituents to do otherwise, they say, noting that workers everywhere pay the federal taxes now up for redistribution.
Of the eight Republican governors who've decided to expand Medicaid, six are from states carried by President Obama. But the governors of Virginia and Wisconsin declined to expand Medicaid although Obama carried them twice. The difference is that Wisconsin and Virginia are led by GOP governors who were, or still are, considering presidential campaigns and the consequences that expanding Medicaid could have on conservative-dominated Republican presidential primaries.
Virginia has a new Democratic governor who may change course on Medicaid expansion when he takes office next month. But Wisconsin Gov. Scott Walker has chosen to burden his state's low-income residents by declining federal funds to expand Medicaid, even though he faces a close re-election battle next year.
States like Wisconsin that decline to expand Medicaid "are forgoing billions of dollars in federal funds, while residents in their states are contributing to the cost of the expansions in other states," said a study financed by the Commonwealth Fund, a private foundation.
That's partly why New Mexico's Republican Gov. Susana Martinez has opted to take federal Medicaid expansion dollars. But her decision was due mostly to the fact that her constituents voted for Obama in both 2012 and 2016.
The latter influence on her decision is not something Martinez acknowledges. "My job is not to play party politics, but to implement this law in a way that best serves New Mexico," Martinez told state legislators.
In a similar vein, Nevada Gov. Brian Sandoval told a newspaper editorial board, "I couldn't sit here and defend to any of you $16 million that just went away because of 'principle.'"
At least 20 Republican governors have turned down the federal money and declined to expand Medicaid, although a few are considering other options. Many say government is too big already, and they suggest Congress will break the promise to keep paying a huge share of the cost.
Louisiana Gov. Bobby Jindal says his state's residents should pass up federal aid even if other states take it. "Our refusal to expand Medicaid," he says, "does in fact help to reduce the growth in federal spending."
Texas Gov. Rick Perry, a 2012 GOP presidential candidate who may try again, called Medicaid expansion a brazen intrusion into state sovereignty. "I will not be party to socializing health care and bankrupting my state," he said.
But North Dakota Gov. Jack Dalrymple, a Republican who agreed to expand Medicaid, told reporters: "We try to leave the politics out in the hallway when we make these decisions. ... Are you going to allow your people to have additional Medicaid money that comes at no cost to us, or aren't you?"
Unlike many governors, Daylrymple won't face voters next year, but in 2016 instead.
The other Republican governor to expand Medicaid in a state Obama lost, Jan Brewer of Arizona, is barred from running again.
The study by the Commonwealth Fund estimated the net losses, by 2022, at $9.2 billion for Texas, $5 billion for Florida and $2.6 billion for North Carolina. All are Republican-led states not expanding Medicaid.
Medicaid now covers 62 million people, one-fifth of all Americans.
The option to expand the program, as part of the president's health care law, could cover millions more by extending eligibility to households earning up to 138 percent of the poverty level. That's about $32,500 for a family of four.
The government will pay the full expansion cost for the first three years, and gradually reduce the subsidy to 90 percent. The traditional federal match for Medicaid averages 57 percent.
Some Republican governors say even a 10 percent share of expanded coverage would burden future state budgets. But others say a 9-to-1 leverage is hard to beat, and they reject the idea that the federal government won't keep its 90 percent funding promise.
Partisan politics surfaced in several state debates. In Idaho, Republican Gov. C.L. "Butch" Otter's advisory panel unanimously recommended expanding Medicaid, and Republican leaders in the GOP-controlled Legislature backed the idea. But Otter said in January there was no hurry, and Idaho should address the entire "broken" Medicaid program over time.
Disappointed Idahoans note that Otter faces a tea party-backed challenger in next year's GOP primary.
"The argument that's going to carry the day in Idaho is politics," said Democratic state Rep. John Rusche, a retired pediatrician. "The governor has to run in the Republican primary."
"The state is missing out significantly," Rusche said, and its taxpayers are subsidizing states that expand Medicaid.
Otter spokesman Jon Hanian said the governor is acting in Idaho's best interest.
Medicaid expansion could emerge in the 2016 GOP presidential primaries.
Govs. John Kasich of Ohio and Chris Christie of New Jersey agreed to expand Medicaid. Walker declined. All are possible candidates in 2016, but Kasich, like Walker, first faces re-election next year.
Kasich had to do an end-run around Republican legislators to tap federal money to cover an extra 275,000 Ohioans under Medicaid.
"It's just the right thing to do," Kasich said.
In New Orleans, the Times-Picayune urged Jindal to "be sensible" and "take the Medicaid money."
"The additional Medicaid money would dwarf the $902 million the state is projected to get in federal transportation funds that year," the editorial said, referring to a popular type of subsidy from Washington.
But Jindal said he would not let Obama "bully Louisiana into accepting an expansion of Obamacare."