As President Obama fights in Congress and the courts to preserve the nation's sweeping healthcare law, the Affordable Care Act faces still another threat to its viability: Republicans in statehouses, many bucking governors of their own party eager to accept its flow of federal dollars.
When a group of Republican governors filed suit to overturn Obama's signature achievement, Wyoming's Matt Mead was among them, arguing the legislation was a vast overreach that violated the Constitution and trampled the right of states to set their own policies.
But after the U.S. Supreme Court rejected that argument, Mead decided it would be foolhardy to pass up tens of millions of dollars the act provided to expand coverage for Wyoming's uninsured adults.
"We have fought the fight," Mead told lawmakers last month in his State of the State address. "We've done our best to find a fit for Wyoming. We are out of timeouts, and we need to address Medicaid expansion."
That argument failed to sway lawmakers in Wyoming's GOP-run Senate, which voted 19 to 11 to reject Mead's proposal; many of the opponents, said Phil Nicholas, the Senate president, had campaigned on a promise to block Medicaid expansion.
A similar dynamic is playing out in legislatures across the country, including Arizona, Florida and Utah, where conservative lawmakers remain a formidable hurdle to momentum building behind the Democratic goal of guaranteeing universal coverage.
Indeed, they have proved far more effective at thwarting the 2010 healthcare law than their Republican counterparts in Washington, who have voted more than 50 times to repeal all or part of the program many call Obamacare, largely to no avail.
Earlier this month, in Tennessee's GOP-led Senate, a committee rejected a proposal to extend Medicaid coverage despite a strong push by the state's Republican governor, Bill Haslam, and waivers from the Obama administration meant to allay conservative concerns.
"I said from the very beginning it would be difficult," Haslam told reporters after his plan was shot down. "I think what you saw today is a measure of just how difficult."
The role of state lawmakers could become even more important depending how the Supreme Court rules this spring in another challenge to the healthcare law. Opponents are seeking to end the public subsidy for residents in as many as 37 states where the federal government operates the marketplace for health insurance.
To restore the subsidies, which are seen as vital to making coverage affordable, legislatures in many states would likely have to vote to run the marketplaces on their own. Currently, just 13 states do so.
Throwing the issue into the hands of state legislators could pose a serious threat to the future of the healthcare law as Republican strength — bolstered by 2014's conservative wave — has reached a high-water mark.
The GOP gained more than 300 legislative seats nationwide as part of its November landslide, taking control of 30 statehouses and well over half the nation's 7,383 legislative seats. That is the most seats Republicans have held since 1920 and the most legislative chambers since Reconstruction.
Although the healthcare law was not an issue in every legislative contest, opposition to the president and his agenda was an overriding theme for many Republican candidates, said Tim Storey, a political analyst at the nonpartisan National Conference of State Legislatures.
"Many of the rank-and-file Republicans are extraordinarily skeptical of anything that's connected to this administration," Storey said, and have "a hard-wired reluctance to consider anything related to Obamacare and Medicaid expansion."
To date, 28 states and the District of Columbia have elected to accept federal aid to expand their Medicaid programs and provide health coverage to low-income residents, a key goal of the Affordable Care Act. Thirteen of those states have Republican governors.
The law provides federal funding to pay for the expansion, though the aid is gradually phased down so that states will ultimately foot 10% of the cost — a prospect many local lawmakers find worrisome, given doubts about the price tag.
"For me, there are three issues: affordability, sustainability and uncertainty," said Jim Dunnigan, majority leader of the Republican-run House in Utah, where GOP Gov. Gary Herbert is pushing to expand Medicaid. "The other thing is the case before the Supreme Court. … That's another big piece of uncertainty."
Obama administration officials and other supporters of the Affordable Care Act hoped the generous aid from Washington would convince more states to back Medicaid expansion. Across the country, hospitals, physician groups and chambers of commerce have heavily lobbied governors and state lawmakers to accept the tax dollars, arguing the additional health coverage would lighten the burden on providers who deliver millions of dollars' worth of free care to uninsured patients each year.
That helped convince Republican governors in several states, including Arizona, Arkansas, Iowa, Nevada, Michigan and Ohio. (A group of conservative Arizona legislators is suing to roll back the state's Medicaid expansion.)
There has been vigorous pushback elsewhere as well. A lobbying blitz led by Americans for Prosperity, the conservative group funded by the billionaire Koch brothers, was instrumental in derailing the proposed Medicaid expansion in Tennessee, and their hope is to replicate that success across the country.
"Our opportunities for success and for good free-market prescriptions, especially around healthcare, government spending and energy, are out there in the states," said Luke Hilgemann, the group's chief executive, who said stopping Obamacare was a top priority of voters the group canvassed in last year's midterm election.
To expand coverage, the administration has signaled a new willingness to give Republican governors more flexibility to adjust their Medicaid programs, including charging premiums and co-payments, a longtime demand of conservatives who argue such cost-sharing promotes greater personal responsibility.
The deal that Indiana Gov. Mike Pence, a staunch conservative, struck with the Obama administration last month to expand Medicaid buoyed supporters' hopes that other GOP-led states would soon follow, including Tennessee and Wyoming.
But in an interview, Mead, Wyoming's governor, sounded less than optimistic after the Senate there rejected his plan, which seeks to expand coverage to more than 17,000 of the state's uninsured.
"I wouldn't say it's dead," Mead said, with a small laugh. "But certainly with what happened … it's even more of an uphill challenge."
Barabak reported from San Francisco and Levey from Washington.