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Republican Party leaders say their No. 1 campaign issue for the midterm elections is thwarting Obamacare. At the same time, a growing number of Republican states are now saying yes to a major provision of the law: expanding Medicaid, the health care program for the poor. The Supreme Court made the expansion optional, and most Republican-led states said no, even with the federal government covering the majority of costs. But now, some are those same states are forging compromises with the White House to accept the federal money. Eric Whitney has the story of how Michigan decided to expand, starting with one of the biggest hospitals in Detroit.

ERIC WHITNEY, BYLINE: Scenes like this one play out hundreds of times a day all across the country.

(SOUNDBITE OF E.R. CONVERSATIONS)

UNIDENTIFIED HEALTH CARE WORKER: The airway is intact. Lung sounds...

WHITNEY: A team of doctors and nurses is assessing a patient just rushed into an emergency room.

UNIDENTIFIED HEALTH CARE WORKER: Do I have an initial blood pressure here yet?

WHITNEY: Because this emergency room is in Detroit, there's about a 1 in 3 chance that the patient being swarmed over is uninsured. That's a much higher rate than the rest of Michigan. That means hospitals like this one - Henry Ford Hospital - end up providing a lot of health care for free. Hospital CEO Nancy Schlichting says even as Detroit has lost nearly a quarter of its population in the last decade, the amount of free or uncompensated care her hospital provides has skyrocketed.

NANCY SCHLICHTING: About seven, eight years ago, we were at about $100 million a year. We're now at $240 million a year in uncompensated care.

WHITNEY: So when the Affordable Care Act offered Michigan the chance to give Medicaid benefits to some 400,000 more residents, Schlichting knew that would mean a lot more people she was already treating would now have a way to pay their hospital bills. She lobbied hard for the state to say yes.

SCHLICHTING: We were very active in advocacy. We got all of our employees engaged. We had over 5,000 emails that went to state legislators, as they were debating the Medicaid expansion for the state of Michigan. So, you know, we almost shamed people into it. You know, how can you turn your back on the people of this state who have lost jobs?

WHITNEY: But Republicans saw themselves as turning their backs on Obamacare, not the people of Michigan. State Rep. Al Pscholka was one of them.

STATE REP. AL PSCHOLKA: Yeah, here you are.

WHITNEY: Pscholka's district is on the southeast shore of Lake Michigan, and includes the historic town of Benton Harbor.

PSCHOLKA: Lake Michigan in December - still a nice view, come on. And you've got ice. (Laughter)

WHITNEY: It's a solidly Republican district. Pscholka says Obamacare doesn't have a lot of fans here.

PSCHOLKA: When people say Medicaid expansion, I think to a lot of us, that meant bigger government. And it meant expanding a program that doesn't work very well.

WHITNEY: Pscholka is a Republican Party leader in the Michigan House. He was asked to look at ways to reform Medicaid. But then, Republican Gov. Rick Snyder came out in favor of Medicaid expansion last year. Snyder argued that if the state didn't expand, the millions of dollars in Affordable Care Act taxes and fees Michigan would be paying would just go to other states, and not come back home in the form of new payments to hospitals and doctors. Pscholka says when he took a hard look at Medicaid, he didn't find the broken, bloated government program he was expecting.

PSCHOLKA: When I understood how it worked, and what we had done in Michigan in the late '90s that was actually pretty smart - we've privatized a lot of that already, which I think a lot of folks didn't understand.

WHITNEY: Medicaid is a government-funded program, but Michigan long ago started contracting with private-sector HMOs to administer it. Pscholka says that makes it easier for conservatives to stomach. And he helped draft legislation to accept Medicaid expansion dollars, but with some conditions. That doesn't mean every Republican in the state is convinced that putting more people on Medicaid is the right way to go. The bill to expand it only passed by one vote in the state Senate.

PSCHOLKA: This is not an easy thing to explain. It's not an easy thing to get up at my county GOP meeting, and look at friends of mine who've been friends of mine for 20 years - who are now shooting darts at me with their eyes, and can't believe that I was even involved in this; not only that I voted for it, but that I was somehow involved in crafting this legislation.

WHITNEY: Pscholka's change of heart on Medicaid earned him a primary challenge from a Tea Party candidate. But she's a long shot to beat him, and those favoring expansion have some strong allies beyond Michigan's popular governor. Hospitals, doctors and the state's small-business association all rallied behind the idea. Cynthia Kay owns a video production company in Grand Rapids with eight employees. She hopes putting more people on Medicaid will help keep the price of her company's health insurance plan down in the future.

CYNTHIA KAY: We're paying for the cost of health care, anyway. Uncompensated cost of care is driving my premiums up every single year. So whether I think I'm paying for it or not, I'm paying for all the people who are using the emergency room as their primary care physician.

WHITNEY: Advocates for the poor are thrilled so many uninsured Michigan residents will now be able to get Medicaid, but worry about some significant details that have yet to be finalized.

JAN HUDSON: I think it's going to be complicated.

WHITNEY: Jan Hudson is an analyst at the Michigan League for Public Policy, which advocates for low-income people. Among the compromises the White House made to win Republican support in Michigan are requirements for some Medicaid recipients to pay for at least part of their care.

HUDSON: Cost-sharing is always a concern for low-income people. The research says that that can be a barrier to people receiving the care that they need.

WHITNEY: The White House is OK'ing cost-sharing in other states, like Iowa and Arkansas. Iowa recipients will pay extra if they overuse emergency rooms, and Michigan will charge them more if they don't stick with wellness plans designed to keep them healthy. Groups that favor Medicaid expansion nationwide point to those kinds of tweaks as evidence that the White House is willing to compromise, and hope that will entice the 23 states that are still resisting expansion to take another look, and work out special arrangements of their own.

For NPR News, I'm Eric Whitney.

MONTAGNE: Eric's and Sammy's stories are part of a partnership between NPR and Kaiser Health News.

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