It’s a great example of raw political irony that some Republican governors can talk out of both sides of their mouth at the same time on Obamacare and Medicaid and get away with it.

Ohio Gov. John Kasich, Michigan Gov. Rick Snyder, Nevada Gov. Brian Sandoval and Arkansas Gov. Asa Hutchinson all share two things in common: They say they hate Obamacare [The Patient Protection and Affordable Care Act [ACA], but love Medicaid expansion that has provided health care coverage to so many of their states’ residents.

The quartet of conservative governors wrote a letter to GOP leaders in Washington—House speaker Paul Ryan and Senate Majority Leader Mitch McConnell—arguing the American Health Care Act [a.k.a Trumpcare], now working it’s way to the House floor for a vote next week, would not work for their respective states.

Medicaid covers more than 70 million people, and its future is expected to be a central issue in the Senate, they wrote. Their shared concern is that the bill, as presently structured, “provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states.”

More than 700,000 Ohioans now have coverage from Medicaid because President Obama expanded eligibility to people with incomes up to 138 percent above the federal poverty level. In total, about three million Ohioans, or more than a quarter of the state’s population, have Medicaid coverage in some form. Medicaid is the federal-state program for the poor, disabled, seniors, mothers and children. In it’s own way, it’s a reverse measure of how well off a state is, since people who earn enough income can buy their insurance themselves or through their employer. Gov. Kasich can look at Ohioans using Medicaid as a measuring stick for how much better he needs to do to create jobs that pay enough to afford market-rate insurance.

The governors reveal their conservative cards early on when they declare Obamacare is unsustainable. They proceed to agree with the Trump White House that replace and reform of the ACA must be simultaneous with repeal, cautioning that it’s “better to get it right than go too fast… [to] avoid the mistakes of Obamacare.”

They see Obamacare as government control of health care when it only regulates for-profit health insurers who have raised their premiums in order to deliver shareholder value each quarter. Stabilizing the private insurance market should be the first priority, they say, but that market has never been stabilized because premiums have gone consistently up over the decades. The ACA has done more to stabilize the market as the rise in premiums has now advanced at the lowest rate ever. Medicaid reform must include options regarding funding structure and affected populations, they say, asking that states have equal access to federal resources to achieve their coverage and access to care goals.

As governors against Washington, they want the state-federal relationship to be fundamentally rebalanced, both from an administrative and financial perspective. Complex reform must incentivize incremental progress that has a positive impact on individual access and health outcomes, they conclude.

“Each state must be permitted to pursue Medicaid transformation in its own way. Governors agree that Washington should not dictate a “one size fits all” solution to Medicaid. We believe that each state should support the ability of another to find a solution that fits their state from among a variety of options. Moreover, after decades of experience operating Medicaid through waivers, it is time to change the law itself,” their letter reads.

Their solution consists of two policy suggestions:

1. States should be given a choice between the following options: a. Enacting structural Medicaid reform by converting financing to a per capita cap or block grant model for one or more population groups. Regardless of which reform option a state elects, reform must allow states an appropriate transition period and the opportunity to use a partial and/or multi-phase approach to implementation. b. Defaulting to the current structure, with reduced federal financial participation. Under this option, Medicaid expansion enrollees would be funded under the traditional match rate for that population.

2. The nature of the current federal-state relationship needs to fundamentally change. Significant new state flexibility and control will be required to effectively manage the financial risk associated with structural reform. Enhanced state authority will also enable states to design more innovative programs focused on achievement of state priorities and outcomes, rather than compliance with processes.

President Trump Likes It, Sen. Brown Doesn’t

President Trump has said he’s 100 percent behind the bill. Others are not. Critics of the House bill say it would make health insurance more expensive for individuals, especially older adults and those with modest incomes. An analysis by the nonpartisan Congressional Budget Office found 24 million people would lose their health insurance over a decade.

Ohio’s senior senator in Washington, Sherrod Brown (D-OH), said he’s hearing from constituents who are terrified of losing their healthcare if the House bill becomes law. “This plan will raise prices for Ohioans – particularly older Ohioans – and kick people off of the coverage they have today,” Brown said recently. “It will threaten jobs across our state by cutting funding for local hospitals that employ hundreds of thousands of Ohioans,” he said, adding, “This plan does nothing to lower healthcare costs for Ohioans, but hands a huge tax break to drug companies and insurance executives who jack up their prices.”

The Republican governors who wrote the letter had nothing to say about the massive redistribution of wealth represented by the tax cuts to the wealthy included in the bill, which has been described by some as more of a tax cut bill than a bill on health care.

Other voices agree more with Sen. Brown than with Gov. Kasich and his GOP compatriots, especially when it comes to women. In a new analysis by the Women’s Public Policy Network (WPPN) of Ohio, deep, permanent cuts to Medicaid and the elimination of Medicaid expansion would threaten coverage for the millions of low-income women and families, pregnant women, women with disabilities, and elderly women that depend on the program for coverage. These cuts, the WPPN analysis said, would shift costs to the states, likely leading to more limited eligibility for enrollment and cuts to coverage benefits. Women of color would be disproportionately impacted by these cuts as black women and Latina women are more likely than white women to be insured through Medicaid.