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Source: Richmond Times-Dispatch, Va.self storageAug. 20--Michigan Gov. Rick Snyder came up with an idea to bank initial savings from expanding the state's Medicaid program to pay for future costs of extending health care benefits to more uninsured people.Virginia got there first.Snyder's Health Savings Fund would follow the same premise as the Virginia Health Reform and Innovation Fund, authorized by the General Assembly this year as part of a budget compromise that opens the door to expanding Medicaid in the state if sufficient reforms are made to the program.The two states, both led by conservative Republican governors, are among more than a half dozen seeking a middle way between expanding Medicaid under the Affordable Care Act and rejecting expansion -- as well as billions of dollars in federal aid to pay for it."There has never been a time when Medicaid has been more in the spotlight politically than it is right now," said Vernon K. Smith, former Medicaid director in Michigan and managing principal of Health Management Associates there.The politics of Medicaid expansion were plain to see Monday, as hundreds of green-shirted opponents rallied in Capitol Square for the second meeting of a legislative commission authorized this year to expand the program, but only after ensuring major reforms.Opponents organized by Americans for Prosperity joined a throng of expansion advocates and lobbyists for health and insurance interests for a nearly three-hour meeting of the Medicaid Innovation and Reform Commission, which itself is politically divided over the possibility of expansion.But Virginia's ongoing debate over the future of its Medicaid program is not unusual, especially in states led by Republican governors who may oppose President Barack Obama's health care overhaul but not the opportunity to reap their states' share of higher taxes paid to carry out the law.Smith called expansion "one of the most significant, most consequential, and politically difficult issues in the history of the Medicaid program."The decision wasn't supposed to be that hard when Obama signed the law more than three years ago. States would expand their Medicaid programs to cover people who earn up to 133 percent of the federal poverty level or risk losing federal matching funds for their existing programs.The U.S. Supreme Court made expansion an option in a ruling last year, saying that the government could not withhold money from states that choose not to expand their programs.Virginia is among more than a half dozen states that Smith said haven't embraced expansion or ruled it out. I迷你倉stead, they've looked for different ways to extend coverage to uninsured, low-income residents while protecting their state budgets and tightening program rules and benefits.In addition to Michigan, Smith outlined expansion options being explored by Iowa, Ohio, Indiana, Arizona -- all led by Republican governors -- and Arkansas, led by Democratic Gov. Mike Beebe. The Republican governors of Tennessee and Pennsylvania also are still exploring their options, he said.Virginia's approach is spelled out in a matrix of 19 areas of reform in three phases, which are specified in the budget language adopted by the General Assembly and signed by Gov. Bob McDonnell.McDonnell opposes Medicaid expansion without significant reforms to control costs to the state in future years, once the federal government scales back its share from 100 to 90 percent of costs."What do I want to see? I want to see the reforms done," McDonnell said Monday.But the governor made clear that the decision ultimately rests with the new commission, which will meet again in October and December, with a public hearing expected before the next meeting."If they say 'done,' Medicaid expansion goes into place," he said.Legislators and state health officials say they have made major strides in getting federal permission to carry out significant reforms to the program, such as coordinating the care of people eligible both for Medicaid and Medicare benefits."I'd say we are a little more than halfway there," said Sen. Emmett W. Hanger Jr., R-Augusta, chairman of the commission and a proponent of expansion.But big concerns remain, especially over the possibility that the federal government will break its commitment to pay 100 percent of the costs of expansion in the next three years and no less than 90 percent thereafter.The budget language adopted this year directs Virginia to reverse the expansion if the government reduces its commitment, but Del. R. Steven Landes, R-Augusta, the commission's vice chairman, said that wouldn't be as easy as it sounds."Once you enroll these individuals, isn't there an expectation that you continue to provide services to these individuals?" Landes asked.Smith said the point is well-taken. "Once adopted," he said, "it's very difficult to un-adopt it."A Guide to Medicaire Expansion in Virginiammartz@timesdispatch.com(804) 649-6964Staff writer Olympia Meola contributed to this report.Copyright: ___ (c)2013 the Richmond Times-Dispatch (Richmond, Va.) 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