At the Central Iowa Shelter and Services in Des Moines, Iowa, health insurance navigator Andrea Pearce stood in a crowded dining hall on a recent day, shouting instructions on how residents can sign up for Medicaid.
"If you do not have insurance and you want to enroll and you have an e-mail address where you know the password," she said, "come to the computer lab we will guide you through the application."
Jerry Gross enthusiastically darted to the front of the line. This tall 56-year-old carries just a duffle bag and his winter coat. He arrived in Des Moines in early December.
He says when he can't find a job in one town, he hitchhikes until he can find work. But he's uninsured, and taking care of his health is always tough.
"I take three different water pills for hypertension. I've got like 10 more days of that left, and after that what do you do?" he says.
When the federal Affordable Care Act called for states to expand Medicaid programs to cover people like Gross, Iowa Republican Gov. Terry Branstad refused. He said he feared the federal government wouldn't come through on its promise to fund the expansion to include childless adults. Iowa was one of many states that initially refused all or part of the federal funds offered.
"We're not just one of those states that said, 'Oh yeah, we'll take the federal money.' No. We said 'no,' " Branstad said during a recent news conference.
Eventually Branstad said "yes," but only if Iowa could take the money on its own terms. The state legislature, which is evenly split between Republicans and Democrats, came up with an alternative: Federal expansion dollars would pay for managed care policies that poor people would select on the HealthCare.gov site.
Iowa's plan also provides incentives for people on Medicaid to monitor their health. Branstad calls it having "skin in the game."
Iowa is one of a handful of states that negotiated or are negotiating with the federal government to customize their Medicaid expansion and still get federal funding. Branstad notes that "other states, like Tennessee and Pennsylvania, are looking at our plan."
The federal Department of Health and Human Services' decision to grant Iowa a waiver to try this idea is not surprising, says Joan Alker, executive director at the Georgetown University's Center for Children and Families, a policy research center. She says that the Obama administration "is willing to bend over backwards to get to 'yes,' " to show Republican governors how much flexibility they have in experimenting with Medicaid expansion in their states.
But "there are some lines they can't and will not cross," Alker says. While Iowa beneficiaries have to pay something for premiums and non-emergency care, recipients "can't be disenrolled if they're unable to pay those premiums," she says. "That's important, because we already have plenty of evidence to suggest that charging premiums to people below [the] poverty [line] will mean that they can't afford them and they're likely to lose their coverage."
Alker worries that the Iowa plan's limitation on benefits for non-emergency medical transportation, which is included in coverage in other states, could have repercussions.
"They're covered for emergency transportation. They're going to get that ambulance to get to the hospital. But we want to make sure folks are able to get their preventative and primary care appointments," Alker says. "When you're talking about people who literally could have limited or no income, that becomes a real barrier."
People are already signing up, so that they'll be enrolled in Medicaid in Iowa beginning Jan. 1.
This story is part of a reporting partnership between NPR and Kaiser Health News.