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By Tony Pugh, McClatchy Washington Bureau (TNS)

WASHINGTON — When Indiana Governor Mike Pence (R-IN) agreed to expand eligibility for his state’s Medicaid program, he made sure to call it “reform” rather than “expansion.”

The change reflects both the unique, conservative features of Indiana’s Medicaid plan as well as a complex political dynamic for Pence, a conservative Republican with rumored presidential aspirations.

By embracing a key pillar of the Affordable Care Act, Pence’s Medicaid plan could tarnish his conservative bona fides with large swaths of GOP voters and opinion makers.

So with party leaders in Washington calling for the repeal and replacement of Obamacare, Medicaid “reform” sounds and looks a lot better to GOP hardliners than the dreaded E-word.

“This has been a long process, but real reform takes work,” Pence said when the deal was done.

His careful wording is part of an awkward political dance that’s being performed nationwide as more Republican governors push for Medicaid expansion, despite tepid support from GOP state lawmakers and a continuing assault on the health care law by Republicans in Congress.

The governors’ efforts have muddied what had been one of their party’s clearest and strongest political messages — their universal disdain for the health care law.

“It’s always a mixed message when one group is doing something and the other’s not. There’s a political element behind all of this,” said Senator Richard Shelby (R-Ala).

But Republican strategist Keith Appell said the conflicting interests on the state and national levels haven’t created intra-party political tension.

“I haven’t seen anything that demonstrates that at all,” Appell said.

The health care law allows states to cover non-elderly adults earning up to 138 percent of the federal poverty level through Medicaid, the state-federal health plan for low-income Americans.

The federal government will pay all medical costs for the newly eligible enrollees through 2016 and no less than 90 percent of their costs thereafter.

To date, 28 states have implemented the Medicaid expansion. This includes 10 with Republican governors whose initial opposition gave way to pressure from voters, hospitals, and patient advocates to grab the federal Medicaid dollars and the new jobs that come with it.

In his recent State of the State speech, Republican North Carolina Governor Pat McCrory called on state lawmakers to join the expansion movement.

“Last session, we came close to passing Medicaid reform, but progress stalled on the one-yard line,” McCrory said. “Let’s run it up the middle and win a victory for families across North Carolina.”

By crafting an expansion that embodies conservative principles, Indiana’s Medicaid plan could become the template for other Republican governors wrestling with the politics of expansion.

It requires most Indiana Medicaid recipients to pay a small monthly premium for coverage that includes dental and vision benefits.

Those who earn below the poverty level won’t have to pay premiums. But if they don’t, they get no vision or dental benefits and must make co-payments toward their care.

Higher-earning enrollees who don’t pay their monthly premiums would lose their coverage in Indiana and couldn’t re-enroll for six months.

While the Obama administration rejected Indiana’s proposed work requirement for Medicaid enrollees, “they were willing to explore some of these more experimental provisions, to see what works and to compromise with these governors that want these folks to have more skin in the game,” said Caroline Pearson, vice president with Avalere Health, a Washington consulting firm.

Any North Carolina expansion plan would likewise “require personal and financial responsibility from those who would be covered,” McCrory said.

Appell said Indiana’s plan is “perhaps the best approach you can take as a conservative.”

“It’s a gutsy call on his part,” Appell said of Pence, “because he also gets some flack.”

Nina Owcharenko, director of the Center for Health Policy Studies at the Heritage Foundation, a conservative Washington think tank, said Indiana’s Medicaid deal takes one step forward by incorporating a number of personal responsibility provisions, “but two steps backwards” by expanding a broken program to new enrollees.

“It doesn’t make sense to me that to reform a program you expand it,” Owcharenko said. “Why would you add more people to something and then say, ‘And now we’re going to figure out how to fix it?’ The boat has a hole in it. It’s sinking, but let’s add more people so it sinks faster?”

Republican Governors Bill Haslam of Tennessee (R-TN), Gary Herbert of Utah (R-UT), and Matt Mead of Wyoming (R-WY) also have called for new Medicaid enrollees to pay premiums. But Haslam’s and Mead’s expansion proposals died earlier this month amid resistance from Republican state lawmakers.

Lobbying by Americans for Prosperity, an influential conservative political advocacy group funded by the billionaire Koch brothers, helped kill Haslam’s proposal in Tennessee. The group opposes the Affordable Care Act.

“Governor (Bill) Haslam was trying to create an independent version of Medicaid expansion, and so far he hasn’t been able to persuade the legislature to do it,” said Senator Lamar Alexander (R-TN).

In Utah, Herbert’s Medicaid plan cleared a state Senate committee vote this week and will soon be debated by the full Senate.

Photo: Medill DC via Flickr

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Jeff Danziger lives in New York City. He is represented by CWS Syndicate and the Washington Post Writers Group. He is the recipient of the Herblock Prize and the Thomas Nast (Landau) Prize. He served in the US Army in Vietnam and was awarded the Bronze Star and the Air Medal. He has published eleven books of cartoons and one novel. Visit him at DanzigerCartoons.

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