Five years after the Affordable Care Act passed, its Medicaid expansion provision is still causing huge fights in state legislatures.

Twenty-four states and the District of Columbia said yes to Medicaid expansion when the law went into effect. Since then, just six more have signed on. States that do get billions of additional federal dollars, but many Republican lawmakers are loathe to say yes to the Obama administration.

The fight’s garnered many headlines in Florida recently as the Republican-led House and Senate are at odds on expansion and the legislative work—including setting a budget—came to a standstill. But the issue has also been hot out west this year where four Republican majority states took up Medicaid expansion. Wyoming said no, Utah’s governor is seeking to negotiate a compromise with Washington to offer legislators, and Alaska legislators are still wrestling with the issue. And after some legislative fireworks, Montana said yes.

Montana lawmakers have been stewing over Medicaid expansion since they said no to it in 2013 – the last time they met. When they reconvened in January, Americans for Prosperity, a conservative group supported by the billionaire brothers Charles and David Koch, staffed up in the state and targeted moderate Republicans, organizing anti-expansion “town hall” meetings in their districts.

But AFP didn’t invite targeted lawmakers themselves and that backfired. Many voters called AFP’s tactics meddling by outsiders, and some AFP meetings were disrupted.

Tea Party lawmakers in the Montana House fought hard against Medicaid expansion. They killed a proposal by Democrats, and then nearly derailed a Republican-sponsored compromise. The House had to bend its rules to even bring the bill to the floor for a vote. But in the end, 20 Republicans felt politically safe enough to cross party lines and vote with all the Democrats to pass it.

Still, at the bill’s signing ceremony Republican Senator Ed Buttrey, who sponsored the bill, said, “This not Medicaid expansion.”

Buttrey says Republicans won important concessions from Democrats to make Montana’s bill more palatable to conservatives. People will have to pay small premiums and the bill also sets up job training and education programs. Buttrey insisted that Montana isn’t just doing the bidding of the White House.

“I’ll say it again, and I hope the media will report this exciting and unique story,” he said.  “This is not Medicaid expansion.”

Montana’s proposal is now on its way to federal officials, who will have the last word on whether it’s legitimate under the Affordable Care Act.

In Alaska, Governor Bill Walker, a former Republican who is independent, has made Medicaid expansion one of his top priorities.

But Republicans leading the state House and Senate blocked expansion during the legislative session that just wrapped up.

One of those opposed is Senator Pete Kelly.

“I think everyone agrees that Medicaid is broken,” he says.  “To put more money into it, to bring more people into it, that’s certainly not going to help its brokenness.”

But surveys show 65 percent of Alaskans favor Medicaid expansion. Supporters testified in large numbers at legislative committee hearings and attended rallies. In one, organized by an interfaith church group, Lutheran pastor Julia Seymour turned the crowd into a choir. She led them in singing, “Medicaid expansion, I’m going to let it shine” to the tune of “This Little Light Of Mine.”

Seymour’s determined to make sure all Alaskans have access to health insurance.

“The Bible tells us that faith, hope and love go on and do not end. And I’m keeping the faith and I am hopeful, but my love for some of the leaders is waning now and then,” she says.

As soon as the regular session ended,  Gov. Walker called lawmakers into special session.

The state is currently facing a massive budget deficit because of the plunge in oil prices. And Walker says even in better financial times, Alaska doesn’t usually decline more than a billion federal dollars.

“If that was a road project or if that was some infrastructure project, we would be all over that,” he says.  “This is healthcare.”

Walker has proposed expanding on his own if lawmakers don’t act but it’s not clear he has this authority. About 40,000 people would qualify for Medicaid if the state expands. About 30 percent of this group are Alaska Natives.

This story is part of a partnership with NPR, Montana Public Radio, Alaska Public Media and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Symphonie Dawson was 23 and studying to be a paralegal while working part-time for a temporary staffing agency when she learned that the reason she kept feeling sick was because she was pregnant.

Living with her mom and two siblings near Dallas, Dawson worried about what to expect during pregnancy and what giving birth would be like, not to mention how to juggle having a baby with being in school.

At a prenatal doctor visit she learned about a group that offers help for first-time mothers-to-be called the Nurse-Family Partnership. A registered nurse named Ashley Bradley began to visit Dawson at home every week to talk with her about her hopes and fears about pregnancy and parenthood.

Bradley helped Dawson sign up for the Women, Infants and Children Program, which provides nutritional assistance to low-income pregnant women and children. They talked about what to expect every month during pregnancy and watched videos about giving birth. After her son, Andrew, was born in December 2013, Bradley helped Dawson figure out how to manage her time so she wouldn’t fall behind IN at school.

Dawson graduated with a bachelor’s degree in early May. She’s looking forward to spending time with Andrew and looking for a paralegal job. She and Andrew’s father recently became engaged.

Meanwhile, Bradley will keep visiting Dawson until Andrew turns two.

“Ashley’s always been such a great help,” Dawson says. “Whenever I have a question like what he should be doing at this age, she has the answers.”

Home visiting programs that help low-income, first-time mothers have a healthy pregnancy and develop parenting and other skills to get and stay self-sufficient have been around for decades. Lately, however, they’re attracting new fans. Home visiting programs appeal to people of all political stripes because the good ones manage to help families improve their lives and reduce government spending at the same time.

In 2010, the health law created the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program and provided $1.5 billion in funding for evidence-based home visiting programs. There are now 17 home visiting models approved by the Department of Health and Human Services, and Congress reauthorized the program in April with $800 million in funds for the next two years.

The Nurse-Family Partnership is one of the largest and best-studied programs. Decades of research into how families fare after participating in it have documented reductions in the use of social programs such as Medicaid and food stamps, reductions in child abuse and neglect, better pregnancy outcomes for mothers and better language development and academic performance by their children, among other things.

“Seeing follow-up studies 15 years out with enduring outcomes, that’s what really gave policymakers comfort,” says Karen Howard, vice president for early childhood policy at First Focus, an advocacy group.

But some experts, while supporting the MIECHV program overall, say that only a handful of the approved models have as strong a track record as that of the Nurse-Family Partnership. They say the standards for what constitutes an evidence-based program are too lenient.

“If the evidence requirement stays as it is, almost any program will be able to qualify,” says Jon Baron, vice president for of evidence-based policy at the Laura and John Arnold Foundation, which supports initiatives that encourage policymakers to make decisions based on data and other reliable evidence. “It threatens to derail the program.”

Nurse-Family Partnership founder David Olds, professor of pediatrics at the University Of Colorado Denver, began testing the model in randomized controlled clinical trials starting in 1977 and continues to conduct long-term follow-up research today.

A study by the Pacific Institute for Research and Evaluation found that the Nurse-Family Partnership reduced Medicaid spending on a first child by 8 percent, resulting in a savings to Medicaid of $12,308 per family served. When adding in cost reductions in food stamps, special education, Child Protective Services and criminal justice costs, total government savings are closer to $19,000 per family, the study found.

However, many of the models approved by HHS do not have a lengthy track record nor strong evidence of having made meaningful changes in mothers’ or their children’s lives, according to Baron.

Although MIECHV programs must show statistically significant effects in order to qualify as evidence-based, those effects need not have any policy or practical importance to qualify, Baron says.

He offered the example of one program that increased the percentage of mothers who brought their babies to the doctor for a one-month checkup, a process measure. But a few years later, further evaluation found no statistically significant effect on child health or safety, no measurable improvement in concrete outcomes.

“We think this is an important program,” Baron says. “I testified for its reauthorization. We just think that as it goes forward the loophole needs to be adjusted.”

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.