AUGUSTA — A handful of Republican lawmakers, if they haven’t already, are about to become the most popular — or, depending on your perspective — among the most reviled legislators in the weeks ahead.

“There is a fair amount of pressure coming from both sides,” Rep. Corey Wilson, R-Augusta, said. 

Wilson, a first-term legislator, is among the five Republicans in the Maine House who have previously voted for an expansion of MaineCare, the state’s Medicaid program, a prospect rank-and-file Republicans and Gov. Paul LePage are dead-set against.

Republican leaders and LePage say the state’s low-income health care program is a constant source of budgetary woe for the state. Expanding it, they say, would be a massive expansion of welfare.

Expanding the program under the federal Affordable Care Act has been a top priority for Democrats over the past two years. They maintain that the expansion, because it would largely be paid for with federal funds, would pump $700,000 a day into the state’s economy.

But Republicans, pointing to a recent report produced by a private consultant hired by the LePage administration, say an expansion would cost the state more than $800 million over the next 10 years.

Republicans also say that until the state does something to provide health care to some 3,100 children, elderly and disabled people on a waiting list for MaineCare, they won’t support expanding the program to cover more Mainers.

Democrats estimate the expansion would give health care to about 70,000 more low-income Mainers; Republicans say the figure is more like 100,000.

“Adding 100,000 able-bodied people to Medicaid is just a bad idea when it comes to our state’s budget and the ability of taxpayers to sustain it,” said David Sorensen, a spokesman for House Republicans. “We don’t intend on meeting halfway on a bad idea. This isn’t a biennial budget bill; it doesn’t need to be passed.”

Sorensen and others say that about half of the people who would be covered under a Medicaid expansion could buy health insurance on the open market and it would be covered by federal subsidies under the ACA. But Democrats say most of the expansion would be for people too poor to be eligible for a subsidy under the ACA.

And while most Republicans are digging in their heels, a few, including Wilson and Rep. Jarrod Crockett, R-Bethel, say there’s more room for compromise on the issue than the party stalwarts are letting on.

Wilson is careful to say he’s not a flat-out yes vote on expansion, but he would support that if the legislation also aims to control costs and improve the quality of the medical care that’s delivered to MaineCare recipients.

“To me, we can use (expansion) as an opportunity to put in measures to control costs,” Wilson said. 

The high cost of care, not necessarily the number of people using MaineCare, is the biggest problem with the system now, Wilson said.

Adding sliding-scale co-payments for emergency room visits or other requirements for MaineCare recipients that encourage preventive care and healthier lifestyles could be elements in a compromise on expansion, Wilson said.

Other ideas include the establishment of so-called “medical homes” — primary care practices in which Medicaid recipients would receive most of their health care instead of at relatively high-cost emergency departments.

Expansion, according to Wilson, shouldn’t be just an expansion of the status quo with MaineCare.

“The entire system needs to be improved to focus not only on lowering costs but improving health outcomes and the quality of the care that is delivered to the patient,” Wilson said.

Wilson said details of what a compromise on expansion might look like were still emerging. 

“I’m not really willing to give specifics, but there’s nothing that isn’t on the table,” he said. “We have a lot of different options to improve the bill that’s out there now.”

The offer on the table so far expands eligibility for an estimated 70,000 more Maine people, but it defunds that expansion in 2016 if a future legislature chooses not to continue it. 

While Democrats have pointed to the sunset provisions as a compromise, noting the state doesn’t have to commit long term to funding the expansion, Republicans have said the bill including the sunset provision is a regurgitation of a failed effort in 2013. A bill expanding Medicaid in Maine passed the House and Senate in 2013 but was unable to survive a LePage veto as the House fell just short of the votes needed to override LePage’s official objection.

Maine political observers agree with Wilson that there will be a great deal of pressure on lawmakers, especially those from more rural districts that host hospitals, to expand.

James Melcher, a political science professor at the University of Maine at Farmington, said Maine’s Legislature has plenty of independent-minded Republicans. They also will want to do what their constituents want in an election year, Melcher said.

“Many Rs in the Legislature have shown a willingness to go against the governor’s policies generally at times, even when LePage is vocal about them,” Melcher wrote in an email message to the Sun Journal. 

He noted that other states headed by Republican governors have decided to accept the federal funding to expand Medicaid in their states and some will see that as a sign Maine should do the same.

“We’re seeing several cases nationally where Republican governors who were skeptical of Medicaid expansion have come to the conclusion that, with the federal money, it’s worth it to expand the program,” Melcher wrote. “John Kasich in Ohio is a prominent recent example, but Rick Snyder in Michigan and others have as well. I suspect some of these legislators see this as a potential for economic stimulus in their districts.”

The Maine Hospital Association and the Maine Medical Association have come out in favor of the expansion. Hospitals say that under the ACA their Medicaid reimbursement rates are being curtailed. For Maine, that means a loss in hospital revenue of about $900 million over the 10 years.

Expanding Medicaid would allow hospitals to recoup that federal loss and to improve health outcomes while providing more people with health care.

Dan Demeritt, a Republican consultant who is working for the Maine Medical Association, said he believes more Republicans will want to support an expansion than the party’s talking heads let on.

“It’s a lot easier to draw a line in the sand than it is to build consensus,” said Demeritt, who once served as LePage’s spokesman. “But you have some Republicans who definitely see an opportunity to achieve fiscal reform in the Medicaid program.”

He said those Republicans will want to come to the negotiation table to deliberate: “That’s what governing looks like. When you say no, that ends the discussion; ‘maybe’ keeps it going,” Demeritt said.

Demeritt agreed that Republican lawmakers in rural districts need to be careful about how deep they want to dig in on an expansion.

“In many rural parts of the state the health care industry remains the biggest employer, or one of the biggest employers” Demeritt said. “There are people with critical needs, so if there is an opportunity to inject additional spending into those industries, Republicans from rural parts of Maine have to consider the potential upside for their districts.”

Crockett, who has announced he won’t seek re-election in 2014, said if Democrats are willing to go along with some other welfare reforms being proposed by Republicans, including to require welfare beneficiaries to show they are looking for work and some reforms on Electronic Benefit Transfer cards, then he believes Democrats will get the votes they need for an expansion.

Those, combined with agreements on cost containment measures such as managed-care proposals that push people away from emergency departments for non-emergency care and other reforms that put “skin in the game” for those on Medicaid, will lead to a compromise that will get bipartisan support, Crockett predicted.

“Everybody acknowledges that we’ve got to reduce the costs of health care,” Crockett said. “I would be willing to go along with it, but I want to see some kind of compromise on the bill.”

The question for Democrats will now be: How many more Republicans will be willing to go along and what kind of compromises will Democrats offer to secure those votes?

sthistle@sunjournal.com