Ohio's 3 million Medicaid recipients are under fire from both Columbus and Washington these days.
"While it is very politically strong to say people will die, the reality is we will all die at some point," said state Rep. Mike Duffey, R-Worthington, talking about limited dollars for funding Medicaid as the GOP legislative majority approved a plan this week that would end health-care coverage for an estimated 500,000 poor Ohioans starting in July 2018.
Gov. John Kasich vetoed the proposed freeze of the Medicaid expansion before signing the state budget just ahead of a midnight deadline Friday.
"I understand the fiscal concerns that we have, but we've been able to manage it," Kasich said. "I wouldn't do anything that's going to put the state in a position of where we couldn't have fiscal stability."
The Republican-led Legislature already has scheduled sessions Thursday where they'll attempt an override vote. Ohio's Republican legislators face potential pushback from their constituents in the politically divided battleground state for not acting to curb government health care spending.
During a talk show last week on ABC, Kellyanne Conway, top adviser to President Donald Trump, addressed the prospect of millions losing Medicaid coverage under the U.S. Senate's proposed revamp of the Affordable Care Act: "If they are able-bodied and they want to work, then they'll have employer-sponsored benefits like you and I do."
The twin efforts to slash the huge state-federal health-care program for the poor raises questions about what Medicaid really does and who benefits.
While Duffey's cost concerns may prove true in the long run, the federal government currently picks up 95 percent of the price tag for those the GOP lawmakers wanted to cut.
And despite Conway's assertion, nearly 80 percent of able-bodied adults receiving Medicaid under the Obamacare expansion belong to households in which someone is employed, and 59 percent are working themsleves, says the Kaiser Family Foundation. But many of those jobs don't provide health insurance.
The 3 million in Ohio who now receive health-care coverage under Medicaid is up from 2 million in 2010, a 50 percent jump in seven years.
The program now pays for:
Half of Ohio births.
70 percent of nursing home costs.
Mental health and addiction treatment for 580,000 adults enrolled under Medicaid expansion alone.
It's not cheap. Medicaid spending totaled $33.6 billion last year, consuming a large portion of the state budget. The money pays hospitals, nursing facilities, doctors, home health aides and other service providers.
The Medicaid expansion allowed under Obamacare expanded eligibility those under making up to 138 percent of the federal poverty level.
Critics say it comes down to money, and to balance the state budget something has to give. The price tag for 700,000 poor Ohio adults covered in the Medicaid expansion hit $4.7 billion this year, although only 5 percent was paid by the state.
The debate on whether to freeze Medicaid expansion benefits in Ohio showed the philosophical divide between the two sides.
"At some point we're going to have to raise taxes or decide what roads not to build or what schools not to fund. It's not sustainable," said Rep. Stephen Huffman, R-Tipp City. "It's a fine balance ... but these are able-bodied individuals, and if they can go out and work, they have other opportunities to secure coverage."
Rep. Emilia Strong Sykes, D-Akron, countered: "Passing the Medicaid expansion freeze and kicking people off of Medicaid is unacceptable, harmful, and cruel and unusual punishment."
In Ohio, about 43 percent of the expansion population works, according to state officials, but they either don't receive health benefits or can't afford the employee share of costs.
States such as Ohio that expanded Medicaid coverage received 100 percent federal funding for 2014 through 2016 and 95 percent in 2017. The share gradually drops to 90 percent by 2020 and beyond.
The U.S. Senate's Better Care Reconciliation Act would cut the federal share for Medicaid expansion to 85 percent in 2021, 80 percent in 2022, 75 percent in 2023 and to the standard rate starting in 2024 -- about 57 percent, per the Congressional Budget Office said.
State Rep. Andrew Brenner, R-Powell, said last week that if the federal government drops its share of the expansion to around 60 percent, making up the difference would cost the state $1.6 billion per year.
The budget office said the Senate proposal would provide $772 billion less for Medicaid over the next decade than projected under the current law, while a House measure approved last month would generate $834 billion less.
The Senate figure is 26 percent less than current law by 2026, and would be 35 percent lower by 2036, the nonpartisan analysis says.
By 2026, 15 million fewer people would have Medicaid coverage under the Senate proposal.
Several times during the presidential campaign, Trump promised not to cut Medicaid.
For instance, in a May 7, 2015, tweet he said, "I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid."
The Associated Press contributed to this report.