Ohio's Republican governor, John Kasich, is no fan of President Barack Obama's health reform law. But he has become an unlikely proponent of one element of Obamacare - expansion of Medicaid healthcare coverage for the poor - and he has a warning for his fellow party members about the moral consequences of blocking it.
"When you die and get to the meeting with St. Peter, he's probably not going to ask you much about what you did about keeping government small, but he's going to ask you what you did for the poor. You'd better have a good answer," Kasich, a Christian conservative, says he told one Ohio lawmaker last week.
"I can't go any harder than that. I've got nothing left."
Most Republicans oppose Obama's Patient Protection and Affordable Care Act as a costly, ineffective and unnecessary expansion of government. But some Republican governors, like Arizona's Jan Brewer and Michigan's Rick Snyder, have broken ranks to embrace the law's Medicaid expansion as a practical way to help the poor while infusing their state budgets with billions of dollars in federal funding to pay for it.
Kasich has gone further. His message of morality goes straight to the Republican Party's allegiance to traditional American values including charity, and should resonate with religious conservatives within its influential Tea Party faction.
"Those groups are important to the Republican Party these days, and thus religious appeals may well help GOP governors win approval from their colleagues in the legislature," said John Green, political science professor at the University of Akron in Ohio.
The visibly frustrated Ohio governor offers no evidence that his fellow Republicans are responding to his comments. But political analysts say moral arguments by Kasich and others could eventually help them win over Republican lawmakers who otherwise fear an electoral backlash for propping up part of Obama's health reforms.
"They're trying to appeal to the more conservative side of that community of primary voters," said Robert Blendon, who tracks the politics of healthcare for the Harvard School of Public Health.
"These state legislators are going to face primaries in less than a year, and on the Republican side, many of the people who turn out to vote will be very anti-Obamacare but also deeply religious," he said.
In neighboring Michigan, Governor Snyder's voice breaks a little when he talks about the potential human toll of not expanding Medicaid to more residents.
"How are you going to feel if you have to go into an emergency room?" he asked after fellow Republicans who control the state Senate left for the summer last week without a vote. "You'll walk in there, and see chair after chair of working poor people - hard-working people - knowing that's their healthcare system, when we could have given them a better answer."
MILLIONS MAY GET SHUT OUT
Allowing Medicaid to cover nearly everyone with incomes of up to 133 percent of the federal poverty line is central to Obama's goal of providing health insurance to millions of uninsured Americans. On those terms, the effort is failing: Almost a year after the U.S. Supreme Court gave each of the 50 states the choice of opting out of the Medicaid provision, only 23 have committed to expand, according to the nonpartisan Kaiser Family Foundation.
As a result, more than 6.3 million people living below the poverty line - $11,490 for an individual and $23,550 for a family of four - are in danger of losing the opportunity to have health coverage next year, according to a Reuters analysis of data from states and the Urban Institute, a nonpartisan research group. That's because they live either in 21 states, which have failed to move forward with the Medicaid expansion on ideological or financial grounds, or in six others that are still debating the issue: Ohio, Michigan, Indiana, New Hampshire, Pennsylvania and Tennessee.
The health reform law allows people with incomes at or above the poverty line to purchase federally subsidized private insurance through new online marketplaces in each state. But the Supreme Court left the law with no provision for helping those below the poverty line.
Analysts say Americans tend to believe falsely that most poor people are covered by the current Medicaid program, which was created in the 1960s and is jointly funded by states and the federal governments with oversight from Washington. But Medicaid covers only 29 percent of working-age people living below the poverty line, according to the Urban Institute. In many states, benefits are restricted to narrowly defined groups including pregnant women, children and the severely disabled.
Arizona's Brewer raised hopes for the Medicaid expansion to go forward in "red states" after overcoming opposition from her own party members by calling a special legislative session and threatening to veto other bills until lawmakers approved the expansion.
Some states have sought to overcome impasses by striking political agreements that would impose new costs on would-be beneficiaries. But negotiations have not always borne fruit, and the federal government has yet to approve any innovations. In Michigan, Senate Republicans declined to vote on a compromise measure that would require new Medicaid enrollees to pay 5 percent of their income on medical expenses, rising to 7 percent after four years.
Other states have considered proposals to make the expansion temporary or use federal Medicaid funds to purchase private insurance plans that could require the poor to meet deductibles and co-pays.
The Obama administration is leaving the door open for states to reconsider their Medicaid position on a quarterly basis in hopes that more will sign on.
2014 PROSPECTS SLIPPING
Meanwhile, Kasich and Snyder are struggling to make sure healthcare benefits are available for more than 820,000 people who live below the poverty line in their states - 474,000 in Ohio and 350,000 in Michigan, according to state estimates.
But the prospects for coverage in 2014 are slipping. Ohio lawmakers nixed Kasich's Medicaid expansion proposal from the new state budget. Snyder says a decision for Michigan needs to come within the next few weeks, but the state's Senate Republican leader, Randy Richardville, has said lawmakers will spend the summer reviewing the issue.
Kasich acknowledges that the Medicaid expansion may have to wait but believes his message will get through. "I will not give up this fight until we get this done, period, exclamation point," he recently told reporters in a hallway briefing in Columbus. "This is not a support of Obamacare. This is a support of helping our communities, our healthcare systems - the poor, the disabled, the addicted and the mentally ill."
The real change may come only after midterm elections for Congress next year, as state leaders wait to see whether Republicans retain control of the House of Representatives and gain control of the Senate.
"If Republicans get control of the Senate and the House, they'll dramatically try to limit this bill. If they don't get control, many of the states saying no to Medicaid will actually start saying yes," said Harvard's Blendon.
(Reporting by David Morgan; Editing by Michele Gershberg, Peter Henderson Douglas Royalty)