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For holdout red states like Kansas, is expanding Medicaid within reach?

by SuperiorInvest

As lawmakers in a nearby hearing room debated last month whether to support her legislation to expand Medicaid, Gov. Laura Kelly of Kansas challenged the state's Republican House speaker to a vote.

“If he thinks he can end this, bring him in,” Kelly, a soft-spoken moderate Democrat, said in an interview in her spacious office suite at the state Capitol in Topeka.

The next morning, in his own office outside the House of Representatives, Speaker Dan Hawkins showed no signs of relenting. He described Medicaid expansion as “almost like the biggest Ponzi scheme ever devised.” The same day, a House committee voted against sending Kelly's bill to the floor, derailing the proposal, at least for now.

The showdown between Kelly and Hawkins represented one fight in a fierce political battle playing out in several state capitals over the future of Medicaid, the health insurance program for the poor. In Kansas and a handful of Republican-controlled southern states, supporters of expanding the program under the Affordable Care Act have renewed their efforts to overcome longstanding Republican opposition, generating a sense of progress.

However, neither Kelly nor supporters of Medicaid expansion elsewhere have managed to advance the legislation far enough to become law, a reflection of the continued political power of conservative ideas about the nature of government-subsidized coverage. and the people who deserve it.

“The fundamental moral question is really where the safety net should be,” said Ty Masterson, Republican president of the Kansas Senate and a longtime opponent of expansion. “And the safety net should be for the frail, the elderly, the disabled and all low-income mothers and children.”

State-level clashes over Medicaid, which is jointly funded by the federal government and states, could have major implications for hundreds of thousands of low-income Americans, and debate over the program's future unfolds with the 2024 presidential campaign. as a background.

In his campaign for re-election, President Biden has highlighted his administration's work to safeguard the Affordable Care Act. Former President Donald J. Trump, the likely Republican candidate, has threatened the health care law in recent months, without detailing his own plans on the matter. Health policy experts have said a second Trump administration could push to block grant Medicaid or allow states to limit the amount of money they spend on the program.

Kansas is one of only 10 states that have not expanded Medicaid under the Affordable Care Act, which allowed adults with incomes up to 138 percent of the federal poverty level, or about $43,000 a year for a family of four, to will qualify for the program. All of Kansas' neighbors have embraced expansion, three of them (Missouri, Nebraska and Oklahoma) through ballot initiatives in recent years.

Those currently eligible for KanCare, as the Kansas Medicaid program is known, include children, parents, pregnant women and the disabled. The income limit for many 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 fall into what is known as the coverage gap, with incomes too high to qualify for Medicaid but too low to be eligible for a heavily subsidized plan through the federal Affordable Care Act marketplace. .

Kelly and other supporters of Medicaid expansion in Kansas have made their case for years. In 2017, the Legislature passed a bill to expand the program, but it was vetoed by then-Republican Gov. Sam Brownback. Ms. Kelly, then a state senator, campaigned for Medicaid expansion in her successful bid for governor next year and in her bid for re-election in 2022.

In his latest attempt to persuade lawmakers to get on board with the expansion, Kelly modified his approach. In December he unveiled an expansion bill that included a work requirement, offering Republicans a concession he thought might convince them.

“I tried everything else and it didn't work,” he said. “I wanted to get it off the table as an excuse.”

Last month at the state Capitol, House and Senate lawmakers held two hearings on Medicaid expansion, the first on the issue in four years, giving supporters of the legislation a sense of progress. Both courtrooms were so packed that visitors were forced to listen from the hallways or file through the overflowing rooms.

There have also been signs of movement in Republican-controlled southern states. In recent months, Republican leaders in Alabama, Georgia and Mississippi have expressed new openness to expanding Medicaid. Mississippi House and Senate lawmakers have approved different Medicaid expansion plans in recent weeks despite intense lobbying from the state's Republican governor, Tate Reeves, who has vowed to veto any bill that reaches his desk. .

“There is momentum,” Kelly said.

There have also been setbacks. The same day Topeka lawmakers blocked Kelly's bill from advancing to the floor, a similar measure in Georgia died in a Senate committee. Masterson, president of the Kansas Senate, argued that resistance in his state and elsewhere showed that the momentum was going in the opposite direction.

Masterson and other opponents of Medicaid expansion have argued that its long-term costs to state budgets are too severe. Supporters have said the economic logic is obvious, since the federal government covers 90 percent of the cost. A 2021 pandemic relief package further sweetened the deal for states that have not yet expanded.

Ms. Kelly said the expansion would benefit the Kansas economy and create thousands of health-related jobs. Hospital and community clinic officials in the state see the expansion as a potential lifeline for rural providers under financial pressure.

Benjamin Anderson, CEO of Hutchinson Regional Healthcare System, a rural community hospital outside Wichita, told lawmakers at hearings last month that, as a lifelong Republican, he opposed the Affordable Care Act. But the state health system's challenges in covering the costs of treating the uninsured had persuaded him to support Medicaid expansion. He noted that his hospital had to cut 80 jobs last year.

“The next generation of doctors wants to work in a situation where they don't have to think about how people pay for care,” he said.

House Speaker Hawkins, who previously owned a health insurance agency, dismissed the idea that Kelly's bill, with its work requirement, could sway voters. Regardless of the legislation, he said, the expansion would inflate the state budget and require taxpayers to pay for the medical needs of healthy adults who could be working and on employer or marketplace plans.

“Are we all supposed to provide them with something that they don't even care enough to go to work and get?” Mr. Hawkins asked. “What happened to our idea in this society that we should be self-sufficient, especially if we are healthy?”

The Kansas Health Institute, a nonpartisan research group, has estimated that about 70 percent of those who would be eligible for Medicaid under the expansion are working.

One who would potentially qualify is Stephen Zook, an uninsured restaurant server in rural Buhler, Kansas, who makes about $15,000 each year and falls into the coverage gap in Kansas. He said he was unable to see a therapist for depression and other mental health needs, and that he had been unable to pay a medical bill of approximately $2,000 he received for a heart monitor last year.

“It's definitely not the people who are lazy,” he said. “These are people trying to improve their lives. I'm trying to improve my efforts as many times as I can. And it’s still not enough to get the coverage I need.”

Melissa Dodge, a single mother of four in Derby, Kansas, who works part-time as a restaurant hostess and is also stuck in the coverage gap, said she was struggling to get by while caring for her daughter's complex medical needs and Everyday tasks like dropping students off at school.

Her doctor is careful not to order lab tests because of the potential unaffordable costs, Ms. Dodge said.

“It's a huge source of anxiety,” she said of not having health insurance. “There is a fear that I refuse to allow to rule my life. But it's there. And I can't not recognize it.”

Hawkins admitted that the politics of the Affordable Care Act had changed as Republican opposition to the law faded, leaving it a less potent issue to campaign against. “I just don't think she has the strength she once had,” he said.

Ms. Kelly said that if expansion supporters failed in the current legislative session, they would test the issue in this year's election campaign. “This will be the number one election issue,” she said.

Ms. Kelly predicted that expansion opponents were fighting a losing battle.

“They have painted themselves into a corner,” he said. “And I think they're having a hard time finding a face-saving way out.”

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