As congressional Republicans begin work on repealing the Affordable Care Act, many of the nation's governors want to make sure that their state budgets don't take a hit during the dismantling process.
They're most concerned about Medicaid, the health insurance program for the poor that's run jointly by the states and federal government. As a result of a Supreme Court decision, states were allowed to decide whether they would expand Medicaid under the ACA; 14 million people have gained health insurance coverage through Medicaid since eligibility for the program was expanded.
While 19 states declined the expansion, primarily because of the opposition of Republican governors and lawmakers, 11 Republican governors did choose to expand the program. Now they're lobbying to keep their citizens covered and billions of dollars of federal Medicaid money flowing.
Among them is Ohio Gov. John Kasich who, along with several other Republican governors, met with GOP members of the Senate Finance Committee last week for a closed-door discussion about the health care law.
Kasich has been anything but quiet on the subject.
In a letter to congressional leaders, Kasich recommended that Medicaid expansion not be repealed, while indicating he's open to some changes, such as in income eligibility. Kasich urged Congress in an op-ed on Time.com to pass an Obamacare replacement at the same time as a repeal.
"For the millions of Americans who have gained health coverage since 2010, it's safe to assume that their idea of fixing Obamacare does not involve ripping away their own health care coverage without a responsible alternative in place," wrote Kasich.
"If I had to pay for my medical costs, I wouldn't be taking no medicine"
Evelyn Johnson is among those who would be affected were the ACA repeal to also roll back the Medicaid. She sat in the back of the cafeteria at a social services drop-in center in Cleveland last week as a pair of health care navigators made calls to help people sign up for Medicaid.
"So far I've got a pair of glasses. They're going to do my teeth," she said of the benefits she has received since getting health insurance.
Johnson, who lives with a friend, does not have children and works as a baby sitter, would not have been eligible for state-backed insurance before the Medicaid expansion, when it was limited largely to low-income children, parents and people with disabilities.
Now, anyone whose income is at or below 138 percent of the federal poverty line, about $16,000 a year for a single person, is eligible.
Without insurance, Johnson said she would not be able to afford the prescription drugs she needs.
"If I had to pay for my medical costs, I wouldn't be taking no medicine," she said. "There's no way. I take too many pills."
Unpopular position with Republicans
Kasich's decision to expand Medicaid was unpopular with Republicans. He fought his own party and sidestepped the state Legislature to get the expansion done.
At an event with business leaders this month, Kasich argued that it has been a good deal for the state.
"If they don't get coverage, they end up in the emergency room, they end up sicker, more expensive. I mean, we pay one way or the other," Kasich said. "And so this has been a good thing for Ohio."
Also defending their decisions to expand Medicaid are such Republican governors as Rick Snyder of Michigan, Brian Sandoval of Nevada and Gary Herbert of Utah.
"So if all of a sudden, that goes away, what do we tell these 700,000 people? We're closed? Can't do that," Kasich said at the business event.
Medicaid covers about 1 in 4 people in Ohio. If the expansion is rolled back, it will mean fewer payments to doctors and hospitals.
"You pull on one thread, you topple the whole tower," said John Corlett, who ran the Medicaid program in Ohio under the previous Democratic governor.
"There's nothing to say that the program can't be improved, that it can't be made better," said Corlett, who now runs a think tank in Cleveland called the Center for Community Solutions. "But just to say we're going to get rid of all of it, and then we'll figure out how to make it better, I think would be really disruptive. It'd be disruptive to healthcare providers, to patients, to insurance companies."
Even if the Medicaid expansion remains, the new Trump administration may make major changes to it in the future.
Last year, Ohio asked the federal government to require beneficiaries to pay into health savings accounts, a request the federal government denied.
"I think that with the constellation in Washington the way that it is, that there's going to be an awful lot of opportunities," said Greg Lawson, a senior policy analyst with the Buckeye Institute, a conservative think tank in Ohio that opposed expansion.
Lawson would like to see limits on federal spending per state, and he hopes Ohio will be able to add a work requirement for some beneficiaries.
"I don't think you're going to see the light switch probably just get turned, and one day it's all going to just disappear," he said. "I think what you're more likely to see is major structural changes to the program that over time that will have budgetary impacts."
But it's not clear yet what shape those changes will take or whether the governor who expanded Medicaid here will support them.