As lawmakers debated whether to support a Medicaid expansion bill in a nearby hearing room last month, Kansas Gov. Laura Kelly dared the state's Republican House speaker to call a vote.
“If you think he can kill him, bring it to him,” Kelly, a soft-spoken moderate Democrat, said in an interview in his expansive office suite at the state Capitol in Topeka.
The next morning, in his office off the House floor, Speaker Dan Hawkins showed no signs of giving up. He described Medicaid expansion as “almost like the greatest pyramid scheme ever devised.” That same day, a House committee voted against sending Kelly's bill to the floor, killing the proposal, at least for now.
The standoff between Mr. Kelly and Mr. Hawkins was emblematic of a bitter political battle being waged in several state capitals over the future of Medicaid, the health insurance program for the poor. In Kansas and a handful of Republican-controlled states in the South, supporters of expanding programs under the Affordable Care Act are renewing efforts to overcome longstanding Republican opposition, creating a sense of progress.
But neither Mr. Kelly nor other local Medicaid expansion advocates have been able to advance enough bills to become law. This reflects the continued political strength of conservative ideas about the nature of government-subsidized insurance and who deserves it.
“This is really a fundamental moral question about where the safety net should be,” said Ty Masterson, Kansas Senate Republican chair and longtime expansion opponent. “And the safety net should be over the frail, the elderly, the disabled, and all low-income mothers and children.”
A state-level conflict over Medicaid, which is jointly funded by the federal government and states, could have a major impact on hundreds of thousands of low-income Americans, and debate over the program's future could end in 2024. It is being developed for the election. background.
In his re-election campaign, President Biden has emphasized his administration's efforts to protect the Affordable Care Act. Former President Donald J. Trump, the likely Republican nominee, has threatened the health law in recent months without providing details about his own plans on the matter. Health policy experts said a second Trump administration could push for blanket Medicaid funding or allow states to cap the amount they spend on Medicaid.
Kansas is one of only 10 states that has not expanded Medicaid under the Affordable Care Act, which provides 138 percent of the federal poverty level, or about 43,000 per year for a family of four. Adults with incomes up to $1,000 are eligible for the program. All of Kansas' neighboring states have adopted this expansion, including Missouri, Nebraska, and Oklahoma through recent ballot initiatives.
The current population of Kansas' Medicaid program, known as KanCare, includes children, parents, pregnant women and people with disabilities. The income limit for most adults to qualify is 38 percent of the poverty level, or about $12,000 a year for a family of four. As a result, about 150,000 people are in the so-called coverage gap, where their incomes are too high to qualify for Medicaid but too low to be heavily subsidized through the federal Affordable Care Act marketplace. be unable to qualify for a plan that
Kelly and other Kansas Medicaid expansion supporters have been making the case for years. In 2017, Congress approved a bill to expand the program, but then-Republican Gov. Sam Brownback vetoed it. Kelly, then a state senator, campaigned for Medicaid expansion in his victory in the gubernatorial race the following year and in his 2022 re-election bid.
Mr. Kelly changed his approach in his latest attempt to persuade lawmakers to move forward with expansion. He unveiled an expansion bill in December that included work requirements, offering Republicans concessions he thought could win them over.
“I tried everything else and it didn’t work,” she said. “I wanted to take that off the table as an excuse.”
Lawmakers from both houses of Congress held two hearings on Medicaid expansion at the state Capitol last month. The hearing was the first on the topic in four years, giving supporters of the bill a sense of progress. Both viewing rooms were so crowded that visitors were forced to listen from the hallway or line up in an overflow room.
There are also signs of movement in Republican-controlled states in the South. In recent months, Republican leaders in Alabama, Georgia and Mississippi have expressed renewed willingness to expand Medicaid. Mississippi House and Senate members have approved various Medicaid expansion plans in recent weeks, despite intense lobbying from the state's Republican governor, Tate Reeves. The governor has vowed to veto any proposed legislation.
“There's momentum,” Kelly said.
There were also setbacks. On the same day that Topeka lawmakers blocked consideration of Kelly's bill, a similar bill in Georgia died in a Senate committee. Masterson, the Kansas Senate president, argued that resistance in his state and elsewhere shows momentum is moving in the opposite direction.
Masterson and other opponents of Medicaid expansion argue that the long-term costs to the state budget are too great. Supporters say the economic rationale is clear because the federal government would pay 90% of the cost. The 2021 pandemic relief package was even more favorable to states that have not yet expanded.
Kelly said the expansion will benefit Kansas' economy and create thousands of health-related jobs. Hospital and community clinic officials across the state see the expansion as a potential lifeline for financially strapped rural health care providers.
Benjamin Anderson, CEO of Hutchinson Regional Health System, a rural community hospital outside Wichita, told lawmakers at a hearing last month that as a lifelong Republican he opposes the Affordable Care Act. But he was persuaded to support Medicaid expansion because the state's health care system is having trouble paying for care for the uninsured. He noted that his hospital had to cut 80 jobs last year.
“The next generation of doctors wants to work in a setting where people don't have to think about how they're going to pay for their care,” he says.
House Speaker Hawkins, who once owned a health insurance agency, rejected the idea that Kelly's bill with work requirements could sway voters. He said that no matter what the bill is, expansion would bloat the state budget and require taxpayers to pay for the health care needs of healthy adults who may be working under employer or market plans. Ta.
“Are we all supposed to give them something they don't care enough about to go to work and get?” Hawkins asked. “What happened to this society’s idea that we should be independent, especially for able-bodied people?”
The Kansas Institute for Health Research, a nonpartisan research group, estimates that about 70% of people who would be eligible for Medicaid under the expansion are working.
One person who may qualify is Stephen Zook, an uninsured restaurant worker in rural Beulah, Kansas, who makes about $15,000 a year but falls under Kansas' coverage gap. He said he hasn't been able to see the therapists he needs to treat depression and other mental health conditions, and he hasn't been able to pay the roughly $2,000 medical bills he received for a heart monitor last year. .
“It's definitely not the people who are lazy,” he said. “People are trying to make their lives better for themselves. They're trying to pull themselves up by the bootstraps as many times as possible. And it's still not enough to get the coverage that they need.”
Melissa Dodge, a single mother of four in Derby, Kansas, works part-time as a restaurant hostess and struggles with coverage gaps to manage her daughter and her daughter's complex medical needs. He said he is having a hard time making a living because of this. Daily tasks such as picking up and dropping off at school.
Doctors are careful not to order tests because they can be costly, Dodge said.
Not having health insurance, she said, “is a huge source of anxiety.” “The fear is there and I refuse to run my life. But it's there. And I can't help but acknowledge it.”
Hawkins acknowledged that as Republican opposition to the Affordable Care Act has waned, its policies have changed and are no longer a strong enough issue to campaign against. “I don’t think it has the punch it used to have,” he said.
Kelly said he plans to test the issue in this year's campaign if expansion supporters are defeated in Congress. “This is going to be the biggest issue in the election,” she said.
Ms Kelly predicted that expansion opponents were fighting a losing battle.
“They've pushed themselves into a corner,” she says. “And I think they're having a hard time finding a way to save face and get out.”