WASHINGTON — While the resistance of Republican governors has dominated the debate over the health care law since last month’s Supreme Court decision to uphold it, several Democratic governors are also quietly voicing concerns about a key provision to expand coverage.
At least seven Democratic governors have been noncommittal about expanding their Medicaid programs, the chief means by which the law would extend coverage to millions of Americans with incomes below or near the poverty line.
‘‘Unlike the federal government, Montana can’t just print money,’’ Governor Brian Schweitzer, a Democrat, said in a statement Wednesday. ‘‘We have a budget surplus, and we’re going to keep it that way.’’
The law would add an estimated 84,000 people to Montana’s Medicaid program, doubling its size, Schweitzer said. Although the federal government would pay the vast majority of the additional costs, Montana’s health and human services department estimates the state’s share would reach $71 million in 2019. Outside groups say the costs would be lower .
The range of state leaders expressing unease suggests that implementing the law could be rough going, with divisions not always breaking along party lines. The topic is likely to factor prominently in this weekend’s meeting of the National Governors Association in Williamsburg, Va. And it has been fueled by a long list of unanswered questions about the choice now before states.
In particular, it is unclear how the court’s pronouncement that states cannot be penalized for refusing to adopt the law’s more generous eligibility standards for Medicaid in 2014 changes the rules governing the expansion.
Will states that opt in have the option of scaling back in future years? If a state that opts out decides it wants to participate at some later point, will the federal government still pay nearly the full cost of covering those who become newly eligible for Medicaid?
And can a state participate partially — for instance, by raising the income cutoff for its program to a level lower than the ceiling envisioned in the law, which is 133 percent of the US poverty line?
Asked to describe state reactions to the Supreme Court ruling, Dan Crippen, executive director of the National Governors Association, offered a one-word reply: ‘‘confusion.’’
The association was one of several — along with the Republican Governors Association and the National Association of Medicaid Directors — to send a letter to Secretary of Health and Human Services Kathleen Sebelius this week with a list of queries.
‘‘The answers to these questions are key,’’ said Matt Salo, director of the Medicaid directors group. ‘‘States need to be making these decisions now, and it’s hard to make them if you don’t have clarity.’’
At least one Democratic governor, Mike Beebe of Arkansas, has also tried contacting the Obama administration directly.
According to spokesman Matt DeCample, Beebe is ‘‘leaning toward’’ the Medicaid expansion, which he said would add between 200,000 and 250,000 Arkansans to the Medicaid rolls in a state whose population is around 3 million. Not only would it bring a significant injection of US funds to the state, but it would be a boon to hospitals, which are treating many poor people for free.
However, DeCample said, the governor has concerns that there be ‘‘state flexibility down the line.’’
So last week, Beebe asked officials at the Centers for Medicare and Medicaid whether, in the event of an unforeseen future fiscal calamity, Arkansas would be able to tighten its eligibility rules and still get the full federal match for those who continued to qualify.
To date, Beebe has received no answer.
In a letter to the governors Tuesday, Sebelius assured them, ‘‘I appreciate that states have questions.’’
However, she offered little in the way of specific guidance, promising instead to address their concerns at meetings scheduled across the country beginning July 31.
Wisconsin’s secretary of health services, Dennis Smith, was skeptical. ‘‘I don’t think we’ll have answers any time soon,’’ said Smith, who directed federal Medicaid operations under President George W. Bush . ‘‘People [in the Obama administration] are putting a brave face on all of this. But they have a mess on their hands.’’
Smith predicted that many states will interpret the rules in ways that conflict with the administration’s position.
‘‘I suspect that judges are going to be hearing a lot of new cases as a result of this ruling,’’ he said. ‘‘I see legal challenges in the future.’’
The earliest could be brought by the state of Maine.