US governors step in on Obamacare repeal as Senate crafts health care bill

May 17 (Reuters) - A group of about a dozen Republican governors is pushing for its own set of national healthcare reforms, flexing its considerable muscle in the national debate over the future of Obamacare as the U.S. Senate begins writing its bill.

Led by Governor John Kasich of Ohio, the governors are using a nine-page proposal they crafted in February as the platform to shape what they think a critical portion of an Obamacare replacement law should look like, according to a half dozen people who helped write the plan.

Among the group's recommendations for the Senate include maintaining the expansion of Medicaid, the government health insurance program for the poor and disabled, while also limiting federal spending for certain populations, according to a copy of the proposal.

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WASHINGTON, DC - MAY 04: Republican House members join U.S. President Donald Trump on stage as he speaks during a Rose Garden event May 4, 2017 at the White House in Washington, DC. The House has passed the American Health Care Act that will replace the Obama era� Affordable Healthcare Act with a vote of 217-213. (Photo by Alex Wong/Getty Images)
WASHINGTON, DC - MAY 04: U.S. Sen. Bernie Sanders (I-VT) speaks during a Stop 'Trumpcare' rally May 4, 2017 in front of the Capitol in Washington, DC. Congressional Democrats joined activists for a rally to urge not to replace Obamacare, also known as the Affordable Care Act. (Photo by Alex Wong/Getty Images)
WASHINGTON, DC - MAY 04: U.S. Senate Minority Leader Sen. Charles Schumer (D-NY) (R) greets House Minority Leader Rep. Nancy Pelosi (D-CA) (L) during a Stop 'Trumpcare' rally May 4, 2017 in front of the Capitol in Washington, DC. Congressional Democrats joined activists for a rally to urge not to replace Obamacare, also known as the Affordable Care Act. (Photo by Alex Wong/Getty Images)
WASHINGTON, DC - MAY 04: U.S. President Donald Trump shares a moment with Speaker of the House Rep. Paul Ryan (R-WI) during a Rose Garden event May 4, 2017 at the White House in Washington, DC. The House has passed the American Health Care Act that will replace the Obama era� Affordable Healthcare Act with a vote of 217-213. (Photo by Alex Wong/Getty Images)
WASHINGTON, DC - MAY 04: U.S. House Minority Leader Rep. Nancy Pelosi (D-CA) (L) gestures as Sen. Patty Murray (D-WA) and Sen. Bernie Sanders (I-VT) wait for their turns to speak during a Stop 'Trumpcare' rally May 4, 2017 in front of the Capitol in Washington, DC. Congressional Democrats joined activists for a rally to urge not to replace Obamacare, also known as the Affordable Care Act. (Photo by Alex Wong/Getty Images)
UNITED STATES - MAY 4: Charlie Wood, 4, of Charlottesville, Va., plays with bubbles during rally on the East Front lawn of the Capitol to oppose the House Republicans' bill to repeal and replace the Affordable Care Act on May 4, 2017. She was born 3 1/2 months earlier and her mother Rebecca, at left, holding a picture of Charlie in the hospital, fears changes to the ACA will negatively effect her care. (Photo By Tom Williams/CQ Roll Call)
Health and Human Services Secretary Tom Price speaks in the Rose Garden of the White House following the House of Representative vote on the health care bill on May 4, 2017 in Washington, DC. Following weeks of in-party feuding and mounting pressure from the White House, lawmakers voted 217 to 213 to pass a bill dismantling much of Barack Obama's Affordable Care Act and allowing US states to opt out of many of the law's key health benefit guarantees / AFP PHOTO / Mandel NGAN (Photo credit should read MANDEL NGAN/AFP/Getty Images)
Ivanka Trump and Jared Kushner listen to US President Donald Trump speak in the Rose Garden of the White House following the House of Representative vote on the health care bill on May 4, 2017 in Washington, D Following weeks of in-party feuding and mounting pressure from the White House, lawmakers voted 217 to 213 to pass a bill dismantling much of Barack Obama's Affordable Care Act and allowing US states to opt out of many of the law's key health benefit guarantees / AFP PHOTO / Mandel NGAN (Photo credit should read MANDEL NGAN/AFP/Getty Images)
UNITED STATES - MARCH 9: Speaker of the House Paul Ryan, R-Wis., conducts a presentation in the House studio of the American Health Care Act, the GOP's plan to repeal and replace the Affordable Care Act, March 9, 2017. (Photo By Tom Williams/CQ Roll Call)
WASHINGTON, DC - MARCH 07: U.S. Secretary of Health and Human Services Tom Price compares a copy of the Affordable Care Act (R) and a copy of the new House Republican health care bill (L) during the White House daily press briefing March 7, 2017 at the White House in Washington, DC. Secretary Price answered questions on the new healthcare bill during the briefing. (Photo by Alex Wong/Getty Images)
U.S. Speaker of the House Paul Ryan speaks to the media about the American Health Care Act at the Capitol in Washington, D.C., U.S. March 15, 2017. REUTERS/Aaron P. Bernstein
WASHINGTON, DC - MARCH 13: U.S. Health and Human Services Secretary Tom Price (L) and Office of Management and Budget Director Mick Mulvaney talk to reporters following the release of the Congressional Budget Office report on the proposed American Health Care Act outside the White House West Wing March 13, 2017 in Washington, DC. Price said 'We disagree strenuously' with the findings of the CBO report about the Republican's attempt to repeal and replace the Affordable Care Act, or Obamacare. (Photo by Chip Somodevilla/Getty Images)
Speaker of the House Paul Ryan speaks at a news conference about Congressional efforts to repeal and replace Obamacare, on Capitol Hill in Washington, U.S. March 9, 2017. REUTERS/Aaron P. Bernstein
WASHINGTON, DC - MARCH 10: U.S. Vice President Mike Pence (4th L) delivers remarks at the beginning of a meeting with representatives of conservative political organizations to discuss the American Health Care Act in the Indian Treaty Room in the Eisenhower Executive Office Building March 10, 2017 in Washington, DC. Pence and Health and Human Services Secretary Tom Price led the meeting that included representatives from the Cato Institute, Tea Party Patriots, the American Conservative Union, Freedom Works, the American Legislative Exchange Council and other conservative groups. (Photo by Chip Somodevilla/Getty Images)
U.S. Speaker of the House Paul Ryan speaks to the media about the American Health Care Act at the Capitol in Washington, D.C., U.S. March 15, 2017. REUTERS/Aaron P. Bernstein
WASHINGTON, DC - MARCH 10: (L-R) U.S. Vice President Mike Pence and President Donald Trump greet House of Representatives committee leaders (L-R) House Budget Committee Chairwoman Diane Black (R-TN), Energy and Commerce Committee Chairman Greg Walden (R-WA) and Education and Workforce Committee Chairwoman Virginia Foxx (R-NC) before a meeting to discuss the American Health Care Act in the Roosevelt Room at the White House March 10, 2017 in Washington, DC. The proposed legislation is the Republican attempt to repeal and replace Obamacare. (Photo by Chip Somodevilla/Getty Images)
U.S. Speaker of the House Paul Ryan speaks to the media about the American Health Care Act at the Capitol in Washington, D.C., U.S. March 15, 2017. REUTERS/Aaron P. Bernstein
U.S. Health and Human Services Secretary Tom Price speaks about efforts to repeal and replace Obamacare and the advancement of the American Health Care Act on Capitol Hill in Washington, U.S., March 17, 2017. REUTERS/Joshua Roberts
A copy of Obamacare repeal and replace recommendations (L) produced by Republicans in the U.S. House of Representatives sit next to a copy of the Affordable Care Act known as Obamacare as U.S. Health and Human Services Secretary Tom Price addresses the daily press briefing at the White House in Washington, U.S. March 7, 2017. REUTERS/Carlos Barria
(L-R) U.S. House Speaker Paul Ryan, U.S. House Majority Leader Kevin McCarthy, and U.S. Representative Greg Walden hold a news conference on the American Health Care Act on Capitol Hill in Washington, U.S. March 7, 2017. REUTERS/Eric Thayer
UNITED STATES - MARCH 14: House Minority Leader Nancy Pelosi, D-Calif., and Senate Minority Leader Charles Schumer, D-N.Y., attend a news conference in the Capitol Visitor Center to voice opposition to House Republican's health care plan, the American Health Care Act, March 14, 2017. The event featured testimony from patients and doctors who benefit from the Affordable Care Act. (Photo By Tom Williams/CQ Roll Call)
UNITED STATES - MARCH 14: From left, Dr. Alice T. Chen, Senate Minority Leader Charles Schumer, D-N.Y., Sen. Maggie Hassn, D-N.H., and House Minority Leader Nancy Pelosi, D-Calif., attend a news conference in the Capitol Visitor Center to voice opposition to House Republican's health care plan, the American Health Care Act, March 14, 2017. The event featured testimony from patients and doctors who benefit from the Affordable Care Act. (Photo By Tom Williams/CQ Roll Call)
Speaker of the House Paul Ryan speaks at a news conference about Congressional efforts to repeal and replace Obamacare, on Capitol Hill in Washington, U.S. March 9, 2017. REUTERS/Aaron P. Bernstein
WASHINGTON, DC - MARCH 08: House Energy and Commerce Committee staff members work during a markup hearing on the proposed American Health Care Act, the Republican attempt to repeal and replace Obamacare, in the Rayburn House Office Building on Capitol Hill March 8, 2017 in Washington, DC. House Republicans were rushing the legislation through the powerful Energy and Commerce, and Ways and Means committees, aiming for a full House vote next week. (Photo by Chip Somodevilla/Getty Images)
WASHINGTON, DC - MARCH 07: House Energy and Commerce Chairman Greg Walden (R-OR) (R) and House Ways and Means Chairman Kevin Brady (R-TX) (L) arrive for a news conference on the newly announced American Health Care Act at the U.S. Capitol March 7, 2017 in Washington, DC. House Republicans yesterday released details on their plan to replace the Affordable Care Act, or Obamacare, with a more conservative agenda that includes individual tax credits and grants for states replacing federal insurance subsidies. (Photo by Win McNamee/Getty Images)
White House Press Secretary Sean Spicer (L) looks on as US Secretary of Health and Human Service Tom Price (R) points to a print-out of the Affordable Care Act (ACA) and a copy of the new plan introduced to repeal and replace the ACA during the daily briefing at the White House in Washington, DC on March 7, 2017. / AFP PHOTO / JIM WATSON (Photo credit should read JIM WATSON/AFP/Getty Images)
WASHINGTON, DC - MARCH 07: House Ways and Means Chairman Kevin Brady (R-TX) (L) and House Energy and Commerce Chairman Greg Walden (R-OR) (R) answer questions during a news conference on the newly announced American Health Care Act at the U.S. Capitol March 7, 2017 in Washington, DC. House Republicans yesterday released details on their plan to replace the Affordable Care Act, or Obamacare, with a more conservative agenda that includes individual tax credits and grants for states replacing federal insurance subsidies. (Photo by Win McNamee/Getty Images)
UNITED STATES - MAY 4: Protesters yell 'shame'' to members of Congress on the East Front of the Capitol after the House passed the Republicans' bill to repeal and replace the Affordable Care Act on May 4, 2017. The protesters support the ACA. (Photo By Tom Williams/CQ Roll Call)
WASHINGTON, DC - MAY 04: U.S. Sen. Bernie Sanders (I-VT) speaks during a Stop 'Trumpcare' rally May 4, 2017 in front of the Capitol in Washington, DC. Congressional Democrats joined activists for a rally to urge not to replace Obamacare, also known as the Affordable Care Act. (Photo by Alex Wong/Getty Images)
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Members of the group, which include governors from Utah, Tennessee and Michigan, are also now looking to form a bipartisan coalition of states to propose reforms for the individual insurance market, according to one source, that they hope the Senate will also use. To see a graphic, click http://tmsnrt.rs/2qOZScv

They have not yet met or decided on specific reforms about the individual insurance market, but the goal is to address issues such as how to make insurance more affordable and stabilize the markets.

The House of Representatives narrowly passed its national healthcare bill earlier this month, called the American Health Care Act, which would slash federal Medicaid funding by more than $800 billion over the next decade.

It has prompted fierce criticism from both Republican and Democratic governors.

Kasich recently called the bill "inadequate," and said it would leave millions of people without affordable coverage and "living in the emergency rooms again."

Pressure is building from their constituents.

The Reuters/Ipsos poll, which has been tracking public opinion on health care issues for the past several years, has found that Republicans are more supportive than they were in 2013 of benefits including expanded Medicaid and insurance subsidies for low-income families and a government requirement that small businesses provide insurance for their employees.

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The latest Reuters/Ipsos poll was conducted online in English across the United States and gathered responses from 2,126 adults, including 887 Republicans. It has a credibility interval, a measure of accuracy, of 2 percentage points for the entire group and 4 percentage points for Republicans.

The governors group is looking to the Senate for massive changes as they begin writing their own bill.

Several groups, from insurers and hospitals to medical groups and patient advocates, are trying to influence the Senate. But the governors carry extra weight because they will ultimately be responsible for implementing whatever healthcare overhaul is signed into law, and Republicans in Congress have repeatedly spoken about the need to have fewer federal regulations apply to Medicaid and commercial insurance.

Under Obamacare, more than 30 states, including about a dozen Republican-led states, expanded Medicaid. One of the thorniest issues Republicans have grappled with is treating both expansion and non-expansion states equally. Governors from both types of states united to craft Medicaid proposals in the hope that their voice would carry added weight and provide a surer path for lawmakers.

The governors are also in the same boat politically as U.S. senators because both are elected statewide, rather than in smaller districts as House representatives are. So many governors and their senators have been better aligned on what healthcare reform should look like, several of the sources said.

Several governors and their staff said they have been in regular contact with their senators, and will be pushing for the Senate to use the governors' set of reforms as a framework in writing its bill.

Senator Rob Portman of Ohio wrote in an op-ed Monday that he and other senators tasked with writing a healthcare bill have continued to engage with governors, "many of who share my concerns about Medicaid but who also want more flexibility to ensure they can design health care programs that meet the individual needs of their states."

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He added that the Senate will continue to work with governors on healthcare reform.

"They are definitely hearing our concerns and questions. They have been very attentive to our interests," said Nathan Checketts, deputy director of the Utah Department of Health.

UNIFIED VOICE

The group of Republican governors has worked to have a unified voice to reconcile needs among a diverse set of states, including Arizona, Illinois, Wisconsin, Arkansas and Nevada. Its leaders, which also include Governor Rick Snyder of Michigan and Governor Doug Ducey of Arizona, deliberately chose some participants from states with influential Republican senators who would become key players in a federal healthcare overhaul.

A 13-member Senate panel has been tasked with writing a healthcare bill, and at least five of its senators are from states from the Republican governors' group, including Portman, Orrin Hatch of Utah, Mike Lee of Utah and Lamar Alexander of Tennessee.

Other Republican senators with governors in the group - including Dean Heller of Nevada and Jeff Flake of Arizona - are up for reelection in 2018.

RELATED: The history of Obamacare

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UNITED STATES - MARCH 23: Pro-choice demonstrators including Stephanie Castro, right, and Sandra Sanchez of the National Latina Institute for Reproductive Health, appear outside of the Supreme Court as arguments were heard in a case which religious organizations are challenging the Affordable Care Act's provision that requires employers to cover birth control in health care plans, March 23, 2016. (Photo By Tom Williams/CQ Roll Call)
US President Barack Obama greets attendees after speakin on the Affordable Care Act at the United Community Center in Milwaukee, Wisconsin on March 3, 2016. / AFP / MANDEL NGAN (Photo credit should read MANDEL NGAN/AFP/Getty Images)
Demonstrators opposed to U.S. President Barack Obama's health-care law, Obamacare, hold signs in front of the U.S. Supreme Court in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
Demonstrators opposed to U.S. President Barack Obama's health-care law, Obamacare, hold signs in front of the U.S. Supreme Court in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
Representative Steve King, a Republican from Iowa, speaks at the Tea Party Patriots podium in front of the U.S. Supreme Court in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
Pamela Hurst, center, speaks to the media as her husband Douglas Hurst, a plaintiff in King v. Burwell, right, looks on in front of the U.S. Supreme Court with Michael Carvin, lead attorney for the petitioners and partner at Jones Day, left, in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
Kathleen Sebelius, former secretary of Health and Human Services (HHS), center, speaks to members of the media in front of the U.S. Supreme Court in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
Demonstrator Donna Hurlock, a medical doctor from Virginia opposed to U.S. President Barack Obama's health-care law, Obamacare, holds a 'No Obamacare' umbrella in front of the U.S. Supreme Court in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
UNITED STATES - MARCH 04: Rep. Louie Gohmert, R-Texas, speaks at a rally outside of the Supreme Court during arguments in the King v. Burwell case which deals with tax credits in the Affordable Care Act, March 4, 2015. (Photo By Tom Williams/CQ Roll Call)
UNITED STATES - MARCH 04: Rep. Louie Gohmert, R-Texas, speaks at a rally outside of the Supreme Court during arguments in the King v. Burwell case which deals with tax credits in the Affordable Care Act, March 4, 2015. (Photo By Tom Williams/CQ Roll Call)
Demonstrator Nell Robinson, a medical student from George Washington University, holds a sign in favor of to U.S. President Barack Obama's health-care law, Obamacare, in front of the U.S. Supreme Court in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
Demonstrator Elodie Huttner holds a sign in support of U.S. President Barack Obama's health-care law, Obamacare, in front of the U.S. Supreme Court in Washington, D.C., U.S., on Wednesday, March 4, 2015. A U.S. Supreme Court argument over Obamacare's tax subsidies divided the justices along ideological lines, potentially leaving two pivotal justices to decide the law's fate. Photographer: Andrew Harrer/Bloomberg via Getty Images
This image taken March 31, 2014 in Washington, DC shows the home page for the HealthCare.gov internet site. Today is the deadline day for uninsured Americans to sign up for coverage through US President Barack Obama's signature healthcare law, the Affordable Care Act. (KAREN BLEIER/AFP/Getty Images)
UNITED STATES - JULY 16: Nicholas Diebel, 14, son of Chairman Pete Sessions, R-Texas, sits at the dais before a House Rules Committee hearing in the Capitol, July 16, 2014, on the constitutionality of a House Republican led lawsuit against President Obama for allegedly overstepping his authority with certain provisions in his health care law. (Photo By Tom Williams/CQ Roll Call)
UNITED STATES - JULY 10: From left, Sen. Mark Udall, D-Colo., Charles Schumer, D-N.Y., Senate Majority Leader Harry Reid, D-Nev., Senate Majority Whip Richard Durbin, D-Ill., and Sen. Patty Murray, D-Wash., conduct a news conference in the Capitol's Senate studio, July 10, 2014, on legislation regarding the Supreme Court decision to allow employers to opt out of the contraception mandate in the Affordable Care Act. (Photo By Tom Williams/CQ Roll Call)
UNITED STATES - JULY 10: Sen. Mark Udall, D-Colo., conducts a news conference in the Capitol's Senate studio, July 10, 2014, on legislation regarding the Supreme Court decision to allow employers to opt out of the contraception mandate in the Affordable Care Act. (Photo By Tom Williams/CQ Roll Call)
Activists opposed the Affordable Care Act's employer contraceptive mandate celebrate outside of the U.S. Supreme Court in Washington, D.C., U.S., on Monday, June 30, 2014. The Supreme Court dealt a blow to President Barack Obama's health-care law, ruling that closely held companies can claim a religious exemption from the requirement that they offer birth-control coverage in their worker health plans. (Pete Marovich/Bloomberg via Getty Images)
Activists who support the Affordable Care Act's employer contraceptive mandate hold signs outside of the U.S. Supreme Court in Washington, D.C., U.S., on Monday, June 30, 2014. The Supreme Court dealt a blow to President Barack Obama's health-care law, ruling that closely held companies can claim a religious exemption from the requirement that they offer birth-control coverage in their worker health plans. (Pete Marovich/Bloomberg via Getty Images)
Activists who support the Affordable Care Act's employer contraceptive mandate demonstrate outside of the U.S. Supreme Court in Washington, D.C., U.S., on Monday, June 30, 2014. The Supreme Court dealt a blow to President Barack Obama's health-care law, ruling that closely held companies can claim a religious exemption from the requirement that they offer birth-control coverage in their worker health plans. (Pete Marovich/Bloomberg via Getty Images)
Anti-abortion demonstrators hold signs during a Priests for Life protest outside the US Court of Appeals for the DC Circuit Court as the Court hears the oral arguments in the 'Priests for Life v. US Department of Health and Human Services (HHS)' case in Washington, DC, on May 8, 2014. The case centers around the HHS mandate in the Affordable Care Act, known as Obamacare, that religious organizations must cover contraceptions and abortion as part of their health insurance benefits, even if that goes against the organization's religious beliefs. (SAUL LOEB/AFP/Getty Images)
Anti-abortion demonstrators hold signs during a Priests for Life protest outside the US Court of Appeals for the DC Circuit Court as the Court hears the oral arguments in the 'Priests for Life v. US Department of Health and Human Services (HHS)' case in Washington, DC, on May 8, 2014. The case centers around the HHS mandate in the Affordable Care Act, known as Obamacare, that religious organizations must cover contraceptions and abortion as part of their health insurance benefits, even if that goes against the organization's religious beliefs. (SAUL LOEB/AFP/Getty Images)
HOLLYWOOD, FL - APRIL 15: Felue Chang who is newly insured under an insurance plan through the Affordable Care Act receives a checkup from Dr. Peria Del Pino-White at the South Broward Community Health Services clinic on April 15, 2014 in Hollywood, Florida. A report released by the Congressional Budget Office indicates that the Affordable Care Act will cost $5 billion less than originally projected for 2014. (Photo by Joe Raedle/Getty Images)
US President Barack Obama speaks about the Affordable Care Act, also known as Obamacare, with Vice President Joe Biden (R) in the Rose Garden at the White House in Washington on April 1, 2014. Hundreds of thousands of Americans rushed to buy Obama's new health insurance plans on March 31, prompting a victory lap from a White House that paid a steep political price for its greatest achievement. The scramble to sign up under Obama's health care law at the end of a six-month enrollment window caused website glitches and long lines at on-the-spot enrollment centers. AFP PHOTO/Nicholas KAMM (Photo credit should read NICHOLAS KAMM/AFP/Getty Images)
MIAMI, FL - MARCH 31: Norma Licciardello sits with an agent from Sunshine Life and Health Advisors as they wait for the Affordable Care Act website to come back on line as she tries to purchases a health insurance plan at a store setup in the Mall of Americas on March 31, 2014 in Miami, Florida. Today is the last day for the first yearly sign-up period and Sunshine Life and Health saw a wait of four hours or more for people to see a health insurance advisor. (Photo by Joe Raedle/Getty Images)
MIAMI, FL - MARCH 31: Norma Licciardello sits with an agent from Sunshine Life and Health Advisors as they wait for the Affordable Care Act website to come back on line as she tries to purchases a health insurance plan at a store setup in the Mall of Americas on March 31, 2014 in Miami, Florida. Today is the last day for the first yearly sign-up period and Sunshine Life and Health saw a wait of four hours or more for people to see a health insurance advisor. (Photo by Joe Raedle/Getty Images)
MIAMI, FL - MARCH 31: Jose Villanueva (L) and Doraisy Avila sit with an agent from Sunshine Life and Health Advisors as they look at a pricing plan available from the Affordable Care Act at a store setup in the Mall of Americas on March 31, 2014 in Miami, Florida. Today is the last day for the first yearly sign-up period and Sunshine Life and Health saw a wait of four hours or more for people to see a health insurance advisor. (Photo by Joe Raedle/Getty Images)
MIAMI, FL - MARCH 31: People stand in the line to register to meet with Sunshine Life and Health Advisors that are selling insurance under the Affordable Care Act at a store setup in the Mall of Americas on March 31, 2014 in Miami, Florida. Today is the last day for the first yearly sign-up period and Sunshine Life and Health saw a wait of four hours or more for people to see a health insurance advisor. (Photo by Joe Raedle/Getty Images)
MIAMI, FL - MARCH 31: Andres Cuartas (L) sits with Mercedes Mujica an agent with Sunshine Life and Health Advisors as he purchases a health insurance plan under the Affordable Care Act at a store setup in the Mall of Americas on March 31, 2014 in Miami, Florida. Today is the last day for the first yearly sign-up period and Sunshine Life and Health saw a wait of four hours or more for people to see a health insurance advisor. (Photo by Joe Raedle/Getty Images)
This image taken March 31, 2014 in Washington, DC shows the home page for the White House site indicating the amount of time remaining before open enrollment for the Affordable Care Act closes. Today is the deadline day for uninsured Americans to sign up for coverage through US President Barack Obama's signature healthcare law, the Affordable Care Act. AFP PHOTO / Karen BLEIER (Photo credit should read KAREN BLEIER/AFP/Getty Images)
A Choose Health Delaware sign stands outside an Affordable Care Act enrollment event in Milford, Delaware, U.S., on Thursday, March 27, 2014. Six million Americans have signed up for private health plans under Obamacare, President Barack Obama said, a symbolic milestone for a government that has struggled to get the law off the ground. Photographer: Andrew Harrer/Bloomberg via Getty Images
Marketplace guide Jim Prim works on the Healthcare.gov federal enrollment website as he helps a resident sign up for a health insurance plan under the Affordable Care Act at an enrollment event in Milford, Delaware, U.S., on Thursday, March 27, 2014. Six million Americans have signed up for private health plans under Obamacare, President Barack Obama said, a symbolic milestone for a government that has struggled to get the law off the ground. Photographer: Andrew Harrer/Bloomberg via Getty Images
A Health Insurance Marketplace application checklist hangs at a Westside Family Healthcare center during an Affordable Care Act enrollment event in Bear, Delaware, U.S., on Thursday, March 27, 2014. Six million Americans have signed up for private health plans under Obamacare, President Barack Obama said, a symbolic milestone for a government that has struggled to get the law off the ground. Photographer: Andrew Harrer/Bloomberg via Getty Images
Certified application counselor Tina Gaffney helps a resident create an account for a health insurance plan under the Affordable Care Act at a Westside Family Healthcare center enrollment event in Bear, Delaware, U.S., on Thursday, March 27, 2014. Six million Americans have signed up for private health plans under Obamacare, President Barack Obama said, a symbolic milestone for a government that has struggled to get the law off the ground. Photographer: Andrew Harrer/Bloomberg via Getty Images
Marketplace guide Stephanie Cantres helps a resident sign up for a health insurance plan under the Affordable Care Act at a Westside Family Healthcare center enrollment event in Bear, Delaware, U.S., on Thursday, March 27, 2014. Six million Americans have signed up for private health plans under Obamacare, President Barack Obama said, a symbolic milestone for a government that has struggled to get the law off the ground. Photographer: Andrew Harrer/Bloomberg via Getty Images
MIAMI, FL - MARCH 20: Raquel Martinez, Maria Celia Escalona, Flora Motell and Armando Mesa (L-R) wait for their names to be called to speak with an insurance agent from Sunshine Life and Health Advisors as they and others try to purchase health insurance under the Affordable Care Act at a store setup in the Mall of Americas on March 20, 2014 in Miami, Florida. The owner of Sunshine Life and Health Advisors, Odalys Arevalo, said she has seen a surge in people, some waiting up to 3 hours or more in line, trying to sign up for the Affordable Care Act before the open enrollment period for individual insurance ends on March 31. (Photo by Joe Raedle/Getty Images)
MIAMI, FL - FEBRUARY 13: Hisham Uadadeh walks out of Leading Insurance Agency after enrolling in a health insurance plan under the Affordable Care Act on February 13, 2014 in Miami, Florida. Numbers released by the government showed that about 3.3 million people signed up for health insurance plans under the Affordable Care Act through the end of January. (Photo by Joe Raedle/Getty Images)
MIAMI, FL - FEBRUARY 13: Hisham Uadadeh enrolls in a health insurance plan under the Affordable Care Act with the help of A. Michael Khoury at Leading Insurance Agency on February 13, 2014 in Miami, Florida. Numbers released by the government showed that about 3.3 million people signed up for health insurance plans under the Affordable Care Act through the end of January. (Photo by Joe Raedle/Getty Images)
US Representative Greg Walden, Republican of Oregon and chairman of the National Republican Congressional Committee, speaks during a press conference about healthcare and the Affordable Care Act, known as Obamacare, at the Republican National Committee in Washington, DC, January 28, 2014. AFP PHOTO / Saul LOEB (Photo credit should read SAUL LOEB/AFP/Getty Images)
JACKSON, KY - JANUARY, 22: Dr. Derrick Hamilton listens to Breathitt County resident Mary Blair's heartbeat during her appointment at the Breathitt County Family Health Center on Tuesday, January 21, 2014 in Jackson, Ky. Despite suffering from a past heart attack and diabetes Blair was able to receive medical coverage through Medicaid expansion under the Affordable Care Act. (Photo by Luke Sharrett/For The Washington Post via Getty Images) Obamacare Affordable Care Act Healthcare Breathitt County
LOS ANGELES, CA - JANUARY 20: Supporters of the Affordable Care Act (ACA) march in the 29th annual Kingdom Day Parade on January 20, 2014 in Los Angeles, California. The Kingdom Day Parade honors the memory of African-American civil rights leader Martin Luther King Jr. and coincides with Martin Luther King Day. (Photo by David McNew/Getty Images)
MIAMI, FL - JANUARY 15: As people stand in line to speak with an insurance agent Dailem Delombard sits with an agent from Sunshine Life and Health Advisors as she tries to purchase health insurance under the Affordable Care Act at the kiosk setup at the Mall of Americas on January 15, 2014 in Miami, Florida. Today is deadline day for those that want insurance to start on February the 1st. According to the owner of Sunshine Life and Health Advisors, Odalys Arevalo, their business selling insurance under the Affordable Care Act has exploded so much so that by the end of the week they will be moving to a 24,000 square foot space at the mall because they have outgrown the kiosk. They have over 25 agents and are seeing hundreds of people daily, last Saturday they saw about 1,000 people with wait times of over 5 hours. (Photo by Joe Raedle/Getty Images)
A woman holding a sign in support of the Affordable Care Act is seen as US President Barack Obama's motorcade returns to his vacation compound from the gym at Marine Corps Base Hawaii on December 29, 2013 in Kaneohe Bay, Hawaii. The first family is in Hawaii for their annual holiday vacation. AFP PHOTO / Kent NISHIMURA (Photo credit should read Kent Nishimura/AFP/Getty Images)
Fliers promoting the Get Covered Illinois health insurance marketplace sit in a box at the Bureau County Health Department offices in Princeton, Illinois, U.S., on Wednesday, Dec. 18, 2013. Todays deadline for Americans to sign up for Obamacare health coverage effective Jan. 1 was extended until midnight tomorrow as heavy traffic to the online enrollment system caused a queuing system to be activated Photographer: Daniel Acker/Bloomberg via Getty Images
Samantha Guzman, an Affordable Care Act navigator with the Bureau and Putnam County Health Department, center, assists Jackie Karns as she shops for health insurance at the Bureau County Health Department offices in Princeton, Illinois, U.S., on Wednesday, Dec. 18, 2013. Todays deadline for Americans to sign up for Obamacare health coverage effective Jan. 1 was extended until midnight tomorrow as heavy traffic to the online enrollment system caused a queuing system to be activated Photographer: Daniel Acker/Bloomberg via Getty Images
MIAMI, FL - DECEMBER 11: Susana Hernandez (L) speaks with Rosaly Hernandez, an insurance agent with Sunshine Life and Health Advisors, about purchasing insurance under the Affordable Care Act at a kiosk setup at the Mall of Americas on December 11, 2013 in Miami, Florida. As Health and Human Services Secretary Kathleen Sebelius tesified in Washington, DC before a congressional panel that the Affordable Care Act website was improving, the Sunshine Life and Health Advisors said, that they are starting to see a steady increase in the numbers of people coming to them to purchase and understand the policies offered under the Affordable Care Act. (Photo by Joe Raedle/Getty Images)
Enrollee Douglas Sparks waits to speak to a health navigator at a health insurance education and enrollment event in Silver Spring, Maryland, U.S., on Saturday, Dec. 7, 2013. Government-run health insurance exchanges are at the core of the Patient Protection and Affordable Care Act of 2010 known as Obamacare that seeks to provide access to health coverage for many of the country's estimated 48 million uninsured. Photographer: Andrew Harrer/Bloomberg via Getty Images
Copies of the application for the Health Insurance Marketplace from the Department of Health and Human Services (HHS) are arranged for a in Washington, D.C., U.S., on Friday, Dec. 6, 2013. The health-care website's improved performance has both U.S. political parties shifting strategies, with President Barack Obama's team preparing a January advertising blitz and a wave of celebrity promotions to boost enrollment, allies said. Photographer: Andrew Harrer/Bloomberg via Getty Images
An affordable health coverage sign stands a health insurance education and enrollment event in Silver Spring, Maryland, U.S., on Saturday, Dec. 7, 2013. Government-run health insurance exchanges are at the core of the Patient Protection and Affordable Care Act of 2010 known as Obamacare that seeks to provide access to health coverage for many of the country's estimated 48 million uninsured. Photographer: Andrew Harrer/Bloomberg via Getty Images
HIALEAH, FL - NOVEMBER 14: Venita Mendez works with Gisselle Rubio, an insurance agent with Sunshine Life and Health Advisors, as she looks to purchase an insurance policy under the Affordable Care Act at the store setup in the Westland Mall on November 14, 2013 in Hialeah, Florida. As the insurance agents continue to help people purchase and understand the policies offered under the Affordable Care Act, U.S. President Barack Obama announced that Americans who have had their health insurance plans canceled because of the Affordable Care Act can keep those plans for another year if they wish to. (Photo by Joe Raedle/Getty Images)
The Healthcare.gov website is displayed on a laptop computer arranged for a photograph in Washington, D.C., U.S., on Monday, Nov. 4, 2013. The race to construct an online insurance exchange by Oct. 1 spurred the Obama administration to use an expedited bidding system that limited its choice of a builder to just four companies, including CGI Group Inc. Photographer: Andrew Harrer/Bloomberg via Getty Images
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As Senate Republicans take up the bill, one of the most complicated policy and political issues they must grapple with is Medicaid reform.

States that expanded Medicaid, such as Ohio and Michigan, have said a healthcare overhaul must protect those who gained coverage under Obamacare. Non-expansion states, meanwhile, have said they do not want to be penalized with less federal funding because they did not expand and therefore cover fewer people.

The governors' proposal recommends maintaining Obamacare's Medicaid expansion and giving other states the opportunity to expand, but capping federal spending on certain populations through either block grants or per capita caps.

It would provide states the option to phase in other groups, such as parents and children, to per capita caps or block grants, and it recommends reducing federal regulations on states and their Medicaid programs.

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