The complexity is obvious.
National exit polls from last month's election showed that 49 percent of voters wanted some or all of Obama's signature legislative achievement rolled back. Among self-identified independents, that number was 58 percent. Among Republicans, it spiked to 81 percent. When asked about the role of government, half of respondents said the notion that government is doing too much fits their views more closely than the idea that government should do more.
Before the election, a national AP-GfK poll suggested that 63 percent of respondents preferred their states to run insurance exchanges, almost double the 32 percent who wanted the federal government to take that role. And the same electorate that tilts toward repealing some or all of the new law clearly re-elected its champion.
That's not the most important consideration for governors who face re-election in Republican states. Georgia's Nathan Deal and Alabama's Robert Bentley, who also face 2014 campaigns, initially set up advisory commissions to consider how to carry out the health care law, but they've since jumped ship. But, unlike others, Deal and Bentley aren't eyeing national office.
Three Republicans who are viewed as potential national candidates — Rick Perry of Texas, Nikki Haley of South Carolina and Bobby Jindal of Louisiana — were full-throated opponents. Jindal, the only one of the three who is term-limited, is the incoming chairman of the Republican Governors Association. In that role, he has co-signed more conciliatory letters to Sebelius asking questions to flesh out how the designs might work.
Republican governors also are feeling quiet pressure from hospitals and other providers.
Deal, the Georgia governor, offers the typical argument for saying no: "We can't afford it." But the law envisions the new Medicaid coverage more or less as a replacement of an existing financing situation that pays hospitals to treat the uninsured. The law contemplates cuts in that program, which already requires state seed money. The idea was that expanding Medicaid coverage would reduce "uncompensated care" costs.
"Some of those cuts were made with the expectation that Medicaid would be expanded and that hospitals would be paid for portions of business that we are not being paid for now," said Don Dalton of the North Carolina Hospital Association.
Dalton's Governor-elect, Republican Pat McCrory, said as a candidate that he opposed Medicaid expansion. Dalton said his industry is leaning on McCrory and legislative leaders, though he commended "their deliberate approach." Similar efforts are underway in South Carolina, Georgia, Missouri and elsewhere.
For Democrats, Anzalone said the framing will be simpler: "You don't want to take a 9-to-1 match? That's a pretty easy investment. These governors who aren't expanding Medicaid, they're basically giving taxpayer money to the states that do."