The stigma of "Obamacare" is so potent in many red states that some Republican leaders are walking a linguistic tightrope, trying to avoid being seen as joining the massive new health care entitlement but still hoping to get a piece of the money being offered.
In Tennessee, the announcement by Gov. Bill Haslam, a Republican, last week that he will reject an expansion of Medicaid under the health law but is leaving the door open to leveraging "available federal dollars" so confused state Democrats that they couldn't decide whether to stage a walk-out or not.
And in Arizona, Gov. Jan Brewer, a well-known conservative, is calling her decision to extend Medicaid benefits to those making up to 133 percent of the federal poverty level a "restoration" — rather than "expansion" — of the entitlement, because her state had to let childless adults fall off the rolls during a budget crunch in past years.
The delicate terminology reflects just how challenging it is for Republican state leaders to strike a balance between insuring their poorest residents under the Affordable Care Act and satisfying conservative allies who are loath to have anything to do with Obamacare — even if straight-talking New Jersey Gov. Chris Christie is an exception to the rule.
"It's simple. We are putting people first," Mr. Christie told state lawmakers in February. "Which is why, after considerable discussion and research, we have decided to participate in Medicaid expansion under the Affordable Care Act."
Yet it's not looking so simple for much of the GOP contingent, who face pressure from all sides in their respective states to make a decision on Medicaid.
"It seems to me the problem Republican governors are finding is that the Medicaid expansion is just really too good a deal to turn down," said Timothy S. Jost, a health-policy specialist at the Washington and Lee University School of Law.
The Supreme Court created much of the dilemma for Republicans in particular in its June ruling on Mr. Obama's health overhaul, upholding the broad outlines of the law but deciding that states may choose whether or not to expand Medicaid without having to risk their existing funds.
The federal government will pay for 100 percent of the expansion through 2016 before scaling back its contribution to 90 percent in 2020, as part of the law's goal of getting millions more Americans covered under a health insurance plan.
Opponents of the expansion say it drives up federal spending and will bust state budgets when the federal match drops in future years. Yet advocates for the poor, hospitals and some business groups are applying pressure on state leaders to take advantage of the federal funds, citing morality and the economy to plead their case.
For many state-level officials, it's a political problem: their acceptance of Mr. Obama's health overhaul is anathema to the Republican Party and tea party factions on the national and local levels.
Mr. Jost said Arkansas, where Republicans are ascendant but still battling Gov. Mike Beebe, a Democrat, might have found a way for states to increase their coverage while not expanding Medicaid.
Mr. Beebe won preliminary approval from the Department of Health and Human Services to use the federal dollars to buy private insurance on the health exchanges under Mr. Obama's law — a move that should make the expansion more palatable for Republicans across the country.
In Nashville, Tenn., Mr. Haslam told state lawmakers he would not buy into Mr. Obama's Medicaid expansion, but is exploring a plan similar to Arkansas' in using federal funds to buy private plans for those who do not have access to health insurance.
Mr. Haslam's spokeswoman, Alexia Poe, said the Arkansas model was "of interest" to the Volunteer State, but the two states' Medicaid programs and approaches to the Medicaid question are different.
"We're saying we need to know all the details before committing to taking the federal funds," Ms. Poe said in an email. "Arkansas seemed to announce what they're doing and are working out the details on the back end."
"We were so confused with the speech," Mr. Fitzhugh said by phone Thursday. "We didn't know if he turned it down or not."
Ms. Poe said the governor is not comfortable with a "pure expansion" of Medicaid, especially after Tennessee was forced to reduce its Medicaid rolls by 150,000 people about eight years ago.
Arizona had to freeze Medicaid eligibility for childless adults as an austerity measure in 2011, leading enrollment to drop by 141,000 people, according to Mrs. Brewer's office.
The governor's spokesman, Matt Benson, said Arizonans had voted twice — in 1996 and through Proposition 204 in 2000 — to provide Medicaid to people at 100 percent of the federal poverty level or less.
About 240,000 people will come on to Arizona's Medicaid rolls if it accepts the federal dollars, he said. Among them, only 57,000 would be part of the "expansion" population as opposed to those voters mandated the state to cover.
That, Mr. Benson said, justifies the use of the word "restoration" to describe Mrs. Brewer's push to accept the federal funds.
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