Half a million uninsured Virginians may be eligible for Medicaid under an agreement now being worked out in Richmond — a deal in which Republican Gov. Bob McDonnell agreed to include Medicaid expansion as part of the budget if Senate Democrats supported a transportation package. The vote-swapping arrangement is classic politics, but it may open the door to half a million poor Virginians receiving health care.

“It’s like the ‘Lincoln’ movie,” said Kyle Konidk, analyst with the University of Virginia Center for Politics. “If you are trying to achieve an objective in politics, a lot of time you can’t be totally pure about it.”

The governor says he remains opposed to expanding Medicaid in Virginia, a key part of President Barack Obama’s Affordable Care Act. But in a series of amendments he submitted to the General Assembly this week, McDonnell left the door open to expanding the program under certain conditions. If the federal government fails to fund 90 percent of the program, for example, Virginia would withdraw from the program. Other conditions include creation of a lockbox to retain temporary savings created by an initial burst of federal money as well as instituting managed care controls to save money and deliver better care.

“We’re seeing a number of Republican governors who opposed it started looking at the bottom line,” said Frank Shafroth, director of the Center for State and Local Leadership. “Medicaid is such a fundamental part of the state’s budget that it wouldn’t be outside the realm of possibility that the governor will call a special session.”

LAST WEEK, Republican Attorney General Ken Cuccinelli issued an opinion that questioned the constitutionality of expanding Medicaid expansion in Virginia. In response to an inquiry from Del. Bob Marshall (R-13), Cuccinelli took aim at powers invested in the Medicaid Innovation and Reform Commission, whose members get to say whether or not the governor’s conditions have been met. Cuccinelli panned this arrangement as “a delegation of the General Assembly’s legislative authority.”

“It is my opinion that the Virginia Constitution prohibits the General Assembly from delegating final legislative authority regarding budget or other enactments to a committee comprised of a subset of members of the General Assembly,” Cuccinelli wrote in the March 22 opinion.

The governor responded Tuesday, crafting new language clarifying the role of the commission. McDonnell’s new budget language sought to clear up any ambiguity about what was necessary to meet the conditions outlined in the agreement. That means that the commission will play a more limited role, one that sidesteps subjective judgments in favor of objective rulings.

“That is different from giving the commission as much latitude as the attorney general was interpreting based on the language that was there previously,” said state Sen. George Barker (D-39). “The governor says that he feels comfortable that this will stand up.”

CREATED IN 1965, Medicaid is an entitlement program to help states provide medical coverage for low-income families and people with disabilities. Since that time, the program has become the nation’s primary source of health insurance for people who live in poverty. Now the Obama administration wants to dramatically increase the number of people who qualify for Medicaid in Virginia. The federal government would pick up 100 percent of the cost until 2016, when Virginia would be on the hook to pay for 10 percent of the program.

“While I remain opposed to the Medicaid expansion at this time due to the unsustainable 1,600 percent growth in Medicaid in the past 30 years, I have helped outline a plan for long-term reform to save money and get better patient outcomes,” the governor said in a written statement this week. “My amendments provide for greater certainty as to the expectations of the General Assembly related to what reform means and what must be done before any potential expansion of Medicaid.”

Some Democrats have accused the Republican attorney general with playing politics on health-care reform, which Cuccinelli tried to challenge as unconstitutional. They say his campaign for governor clouds any objectivity he might have on the issue, and that his opposition to the constitutionality of the commission’s role is a thinly veiled political maneuver designed to build support among the Republican base.

“I believe the attorney general is incorrect that these phases are subjective because there are clear deliverables,” said Del. Patrick Hope (D-47). “There will be white smoke, and we will know when these reforms have been accomplished.”

ANOTHER PROVISION of the Affordable Care Act is also creating deep divisions in Virginia over the issue of abortion. The federal health care reform calls for the creating of an exchange in the commonwealth where uninsured people who make too much money to qualify for Medicare can sign up for coverage. This week, McDonnell said he wants to prohibit abortion coverage through insurance plans purchased through the exchanges. As legislators gather for their veto session next month, this provision may be targeted by a number of Democrats who say it limits a woman’s right to choose.

“We cannot permit far right-wing ideology to dictate personal medical decisions or to interfere with business agreements,” said Sen. Barbara Favola (D-31). “It is very demeaning to women, to their physicians, and to all Virginians.”