Michigan and Ohio are the biggest of the last few states still on the fence about Medicaid expansion.

And Michigan seems close to endorsing expansion. Backed by both the Obama administration and conservative Republican Gov. Rick Snyder, the expansion of Medicaid to an estimated 470,000 Michiganders hangs only on a vote in the state Senate.

No one expected it to progress this far. But June 13, 2013, the Michigan House of Representatives voted 76-31 to expand Medicaid eligibility in line with the Affordable Care Act.

Snyder, who had been pushing hard for passage of HB 4714, was furious a week later when the state Senate adjourned for the summer without voting on the bill. He rushed back to Lansing from a trade mission to Israel and began haranguing senators to take a vote, not a vacation. He urged Michigan citizens to bug the living daylights out of their senators. Now billboards along the state's highways urge a vote in favor of Medicaid expansion.

Last week in Traverse City, speakers at the Michigan Association of Health Plans annual conference expressed near-certainty that Medicaid expansion would pass the Senate by the end of the summer.

How did the Michigan Republican legislative caucus make this stunning reversal from near-unanimous opposition earlier in 2013 to support for expansion. Four Republicans and three Democrats on a MAHP panel tried to explain.

Rep. Mike Shirkey, a staunch conservative, chairs the House subcommittee that first reviewed the bill. His first impulse was to make sure the bill died right there, but, determined to do right by the process, he looked hard at the arguments for expansion. For him, the ah-ha! moment was when he realized that Medicaid expansion actually lowered taxpayer liability. I started out a hard no; I ended up a complex and confident yes, he said, despite the fact that it was a positive action in support of a federal act I abhor.

Rep. Mike Callton believes his vote for Medicaid expansion may cost him his seat. Tea Party constituents have targeted him for defeat in primaries next year, but he has no regrets. The same 50 Tea Partiers call my office every day. So there are 50 of them and 5,000 of my constituents are getting insurance. If I go down, that's how I'm going down, he said.

Every member of the panel, across party lines, said they were certain that the state will be able to pull out of the expansion in three years if the federal money is cut. All states have that right, Shirkey said.

Rep. Al Pscholka called the House vote for Medicaid expansion the best example of bipartisanship in my three years in office.

Rick Murdock, executive director of MAHP, shared projections that show Medicaid outstripping both large-group fully insured and large-group self-insured commercial enrollment by 2020, with a simultaneous sharp decline in the number of uninsured.

Callton expressed regret that the Legislature failed to authorize a state health exchange. Michigan in 2014 is defaulting to a federally facilitated exchange, which Callton likened to a Chinese finger puzzle pulling the nation's healthcare industry ever closer to single payer. ?The more we resist, the tighter it gets.

State Sen. Jim Marleau, a Republican, said he was proud of his vote for a state exchange, even if the proposition ultimately failed. Marleau acknowledged that he had voted for last-ditch compromise amendments to save the 2012 bill (SB 693) made by fellow panelist Rebekah Warren, a progressive Democrat. Cancer doesn't know if you've got an R or a D after your name, he said. It just comes.

So now a Senate work group is studying the expansion during the summer recess. Several speakers predicted, with confidence, that a bill will emerge from the Senate work group by the end of the week. And that before the end of the summer, during one of the Senate's summer in-session days, that bill will pass.

Follow Lyda Phillips on Twitter @LydaPhillipsHLI

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