Health care: An offer they can't refuse MOST Republicans detest Barack Obama's health reforms, but Republican governors have been especially opposed. In 2010"s election, they used Obamacare to cudgel Democratic opponents. Once in office, many refused to implement the law. Last year they brought their fight against it to the Supreme Court. But the law still stands. And some Republican governors are coming round. Eight now say they will accept Obamacare's money to expand Medicaid, the federal-state programme for the poor. This includes two particularly prominent governors: Florida's Rick Scott (pictured overleaf) and, as of February 26th, New Jersey's Chris Christie. More governors may follow suit. For Democrats, the shift is a political victory. To many conservatives, it is a betrayal. But the biggest implications are for policy, not politics. After years of doubt, America's largest health programme is on the brink of transformation. The hard work has just begun. Historically Washington has required (and subsidised) states to cover only subsets of the poor, such as pregnant women. Obamacare changed that. From 2014, states would have to cover all adults with incomes of up to 138% of the federal poverty level ($15,415 for an individual in 2012; $31,809 for a family of four). If states complied, Washington would pay for 100% of the expansion from 2014 until 2016 and at least 90% thereafter. But if the states refused, federal aid for their existing Medicaid programmes would be slashed. The Supreme Court deemed this ultimatum too harsh. States should be allowed to make a free choice whether to expand Medicaid or not. Many Republicans said they wouldn't. But since Mr Obama's re-election, some have changed their minds. Among the reasons for this are that failing to expand Medicaid would leave millions of Americans in the lurch. Thanks to a quirk in the law, about 11.5m adults earning less than 100% of the poverty level would qualify for neither Medicaid nor for Obamacare's insurance subsidies for soon-to-be-mandatory health coverage. Governors unmoved by this also face a powerful financial argument. Expanding Medicaid requires states to spend only $8 billion more from 2013 to 2022 than they would otherwise, according to the Urban Institute, a think-tank. This is an increase of just 0.3%. Federal spending, however, would rise by $800 billion, a jump of 21%. That is an offer that is hard to refuse. In the next two years 21 Republican governors are up for re-election. Mr Christie, who faces an election in November, said on February 26th that Obamacare is "wrong for New Jersey and for America." But he will expand Medicaid anyway, and so save his state $227m next year alone. Exactly how many states will expand their Medicaid coverage is still unclear. More governors may succumb to the arithmetic. Some may face opposition from conservative state legislatures. But Medicaid looks certain to get bigger. The next challenge is to improve it, too. Medicaid's costs are unsustainable. It gobbles up more state money than any other programme, accounting for 24% of spending. Many states, including Florida, want to cut costs by enrolling patients in tightly-managed private plans. Even more commonly, states have slashed payment rates to hospitals. But this cannot continue forever. Low Medicaid rates prompt hospitals to raise prices for private insurance. And if rates get too low, more doctors will simply stop accepting Medicaid patients. Mr Obama's Department of Health and Human Services (HHS) has supported big payment cuts. For example, it approved California's 10% cut to payment rates; that decision is being challenged in court. But it is also trying to prompt broader change. For example, on February 21st the department announced nearly $300m in grants to help states improve their public-health programmes, including Medicaid. Much more is needed, argues Kathleen Nolan of the National Association of Medicaid Directors. Most important, Ms Nolan argues, it should be easier for states to revise their programmes; today many changes require a lengthy application to HHS. Such debates are likely to heat up in the coming years. Reforming Medicaid may turn out to be even harder than expanding it.