While Obamacare remains wildly unpopular in conservative circles, eight Republican governors are embracing at least part of the law this year by choosing to expand Medicaid eligibility to millions more poor residents in their states. Medicaid expansion is one of the Affordable Care Act's major building blocks.

If you go

Roper St. Francis Healthcare will host a community discussion about Medicaid expansion and the Affordable Care Act in Roper Hospital's Irene Dixon Auditorium, 316 Calhoun St. from 5:30 to 7 p.m. Wednesday.

Panelists will be Robert Greenwald, a professor at Harvard Law School; Bill Settlemyer, founder of the Charleston Regional Business Journal; and Rozalynn Goodwin, vice president for community engagement at the South Carolina Hospital Association.

The event is free. A reception will follow the panel discussion.

Some of these governors are expanding the low-income health insurance program exactly as the Affordable Care Act intended, by covering any individual who earns up to $15,856 a year - equal to 138 percent of the federal poverty level. Other conservative state leaders struck compromise expansion plans with the federal government.

Medicaid expansion key dates

March 23, 2010: The Patient Protection and Affordable Care Act is signed into law by President Barack Obama. A key provision of the legislation widely expands Medicaid coverage for low-income citizens.

Jan. 31, 2011: A federal judge in Florida rules that the Affordable Care Act is unconstitutional. Half of all states, including South Carolina, challenge the law's legality.

June 28, 2012: In a 5-4 vote, the U.S. Supreme Court upholds the law's constitutionality, but decides that states are not required to accept federal money to expand Medicaid.

Jan. 16, 2013: In her State of the State address, Gov. Nikki Haley says, "As long as I am governor, South Carolina will not implement the public policy disaster that is Obamacare's Medicaid expansion."

March 12, 2013: The S.C. House of Representatives rejects a proposal that would have expanded Medicaid eligibility in South Carolina.

Jan. 1, 2014: Medicaid expansion is implemented in 25 states.

South Carolina Gov. Nikki Haley isn't one of them, but this isn't stopping Medicaid expansion advocates in this state from making their voices heard on behalf of the estimated 340,000 South Carolinians who would qualify for Medicaid if the state expanded the program.

Most Republican governors, including Nikki Haley, are not expanding Medicaid in their states using federal money available through the Affordable Care Act, but several are.

In January, Utah Gov. Gary Herbert became the latest Republican governor to announce his intention to expand coverage for low-income residents. Details about the proposed Utah expansion have not been finalized yet.

The following states led by Republican governors will provide coverage with Medicaid expansion money starting this year: Arizona, Iowa, Michigan, Nevada, New Jersey, New Mexico, North Dakota, Ohio.

Kaiser Family Foundation

And some policy experts say proponents for Medicaid expansion are more vocal and better organized this year than ever before.

"There's a growing, tangible argument that this is really bad, that we're missing the boat," said Mark Tompkins, a political scientist at the University of South Carolina. "The sense that we've missed an opportunity is growing."

"Truthful Tuesday" protesters rallied twice at the Statehouse this year in favor of expanding Medicaid. Roper Hospital will host a forum in Charleston on Wednesday sponsored by 32 local and national groups, including the American Heart Association, AARP of South Carolina and the United Way, to raise awareness about the issue. Organizers say they expect at least 200 people to attend. A similar forum is planned in Columbia on Thursday.

Haley's top health care cabinet member was invited to speak at both events but declined.

"Why are you going to debate something that's a moot point for at least the next several years?" said S.C. Medicaid Director Tony Keck.

'Not a dead issue'

Almost immediately after the Supreme Court ruled in 2012 that states could opt out of the Affordable Care Act's Medicaid expansion, Haley announced that South Carolina would have no part of it.

"From rising health care costs, to not being able to keep your doctor, the past months have proven that Obamacare is wrong for our country and for our state and Governor Haley's decision to fight against it was the right one," said Haley spokesman Doug Mayer. "South Carolina needs health care solutions that are right for South Carolinians not Washington - and we will continue pursuing those state based solutions."

Last year, the Legislature agreed with the governor by voting down a proposal to accept federal money for expansion.

Still, it's a discussion that will likely resurrect each year.

"It's certainly not a dead issue," said House Speaker Bobby Harrell, R-Charleston. "It's going to come up every year for the next several years in states all over the country."

Harrell said he doesn't anticipate that the General Assembly will sign off on Medicaid expansion in South Carolina, but advocates say this is still a debate worth having.

"More people are just catching on that it's the right thing to do. It's logical," said Mark Dickson, vice president of mission at Roper St. Francis Healthcare. "Whether it passes or not this year is a separate issue."

'Robust debate'

The Affordable Care Act mandates that the federal government pay 100 percent of Medicaid expansion costs in states that choose to participate starting Jan. 1 this year through the end of 2017. By the nonprofit Kaiser Family Foundation's count, 26 states are expanding their Medicaid programs in 2014. South Carolina is one of 19 states that will not. By doing so, this state is turning down an estimated $4.1 billion from the federal government that would have covered the expansion costs through 2017.

A handful of states are still debating whether to expand Medicaid.

"This is an issue that's ongoing," said Ashley Redmond, the Ryan White HIV/AIDS Program director at Roper St. Francis Healthcare. She helped organize the Wednesday forum at the hospital. "We feel like it's important to get this back in the legislators' minds."

Keck agreed that Medicaid expansion is the Legislature's choice to make. That's one of the reasons why he said he decided against attending the Roper Hospital forum.

"We've had a robust debate (last year). I spoke to several Rotarys, several chambers of commerce, at forums organized by advocates. I spoke on radio shows, TV shows. I spent many, many hours getting out and talking to people about this - and not just talking to people who agreed with us," he said. "It's in the Legislature's hands now."

Paying for expansion

Even though the General Assembly declined the federal money this year, it could change course - however unlikely lawmakers say that might be. There is no stipulation in the federal law that requires states to choose Medicaid expansion now or never.

After 2017, participating states must chip in a small percentage of the bill for expansion - eventually 10 percent by 2020 - which is why the Supreme Court decided states could not be compelled to participate.

The federal government will continue to pay 90 percent of Medicaid expansion costs after 2020, which is a larger percentage than it currently pays for patients who already are eligible for the program.

The $6.5 billion state Medicaid agency, which covers more than one million residents in South Carolina, is funded by a combination of state and federal money. The federal government contributes about 70 percent toward the program's overall cost.

While South Carolina isn't accepting federal money to expand Medicaid eligibility under the Affordable Care Act, the program is growing here anyway.

Membership grew from 1.02 million South Carolina residents in fiscal year 2011 to 1.15 million during the 2013 fiscal year.

Keck estimates that number will continue to increase as some 200,000 people who are eligible under current rules but unenrolled for a variety of reasons sign up for Medicaid cards. He has requested that the General Assembly approve a $6.9 billion budget for the upcoming fiscal year to meet this growing demand.

'Truthful Tuesday'

Loreen Myerson, an Affordable Care Act navigator based in Charleston, helps Lowcountry residents enroll in private insurance policies offered on the federal government's new insurance marketplace. She also is an activist for Medicaid expansion, and helped organize a caravan of protesters last week to rally on the Statehouse steps for "Truthful Tuesday."

"We're working with folks from groups all over South Carolina to make sure that Medicaid expansion is an issue that's still on the table and that's still under discussion," Myerson said.

Walter Durst, 60, of Columbia, rallied alongside Myerson and her group last week during the protest.

Although he's poor, unemployed and qualifies for food stamps, Durst doesn't qualify for Medicaid because he has no children. Childless adults without a qualifying medical condition are not eligible for Medicaid in South Carolina, no matter how poor they are.

Medicaid expansion would have revised those rules, but Durst isn't optimistic that South Carolina leaders will change their minds.

"The way our state works, it's not really looking out for the people," Durst said. "It's looking out for their jobs."

Myerson is quick to note that Haley is up for re-election in November.

"Our position is that either our governor needs a new policy or we need a new governor," she said.

Post and Courier Reporter Cynthia Roldan contributed to this article.