How political maneuvering derailed a red state’s path to Medicaid expansion

Reviewed by James Ives, M.Psych. (Editor)Sep 6 2019

This was supposed to be the year Medicaid expansion finally happened in Kansas.

Democratic Gov. Laura Kelly, elected in November, had run on the issue. She triumphed in a state that had gone for Trump in 2016 by more than 20 percentage points and replaced a Republican governor who had vetoed a previous expansion bill.

Approximately 130,000 low-income people — roughly 4.5% of the 2.9 million people in the state — would be newly eligible for health insurance under the expansion, which is possible because of the federal Affordable Care Act.

But, this time around, a bill to enact Medicaid expansion never got to the Senate floor, even though the new governor and a newly empowered coalition of Democratic and moderate Republican legislators supported it.

At every turn, a handful of Republican leaders managed to block its progress, linking expansion to the welfare state and what one of them called "the abomination of Obamacare."

And so Kansas remains one of the 14 states not to have expanded the health care program that helps disabled or lower-income people. It joined the ranks of Wisconsin and North Carolina, where fellow Democratic governors have not been able to overcome maneuvering by GOP-controlled legislatures to push through an expansion plan.

"There's a growing sense of impatience and anger at the fact that four legislators are stopping the will of the legislature and the governor," said Moti Rieber, head of the faith-based advocacy group Kansas Interfaith Action.

Expansion advocates will try again in 2020.

Nationwide, many state-based Republicans who once resisted Medicaid expansion are now reconsidering it as health costs have increased and the idea has grown in popularity among voters, said Adam Searing, an associate professor of practice at Georgetown University's Center for Children and Families.

"People are getting worried about their elections," he said. "The argument that 'This is expanding welfare to undeserving people' is an argument that's losing its strength as you see health care costs going up."

Medicaid expansion has also steadily gained traction as it has been framed as a way to recoup federal tax money and stop rural hospital closures because they would deliver less uncompensated care.

In a November poll, 77% of Americans favored expanding Medicaid, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

But as support has grown, holdout politicians are deploying a new playbook like that used here to prevent the adoption of the measure: slow-walking bills, undermining grassroots ballot measures or utilizing procedural roadblocks, then adding provisions with a conservative twist that make passage unlikely.

In deep-red Utah, Idaho and Nebraska, GOP leaders either delayed or significantly changed the eye-popping Medicaid expansion ballot initiatives that voters approved in 2018.

In Missouri, the Republican governor recently created a task force to look into Medicaid expansion. Some see this as an effort to defuse energy from a brewing grassroots ballot initiative.

In Georgia, the legislature and governor have approved movement toward a partial Medicaid expansion that could include work requirements for many adults who gain coverage.

Here in Kansas, Republicans are now developing a proposal for 2020 that includes work requirements and further income restrictions — which the governor might not sign and could face federal rejection.

"It's just getting to the point where it seems outrageous that this is not getting a fair chance," said April Holman, head of the Alliance for a Healthy Kansas, a group lobbying for expansion.

What Happened In Topeka

Throughout Kelly's close gubernatorial race against Trump favorite Kris Kobach, she told Kaiser Health News, any mention of Medicaid expansion would always land applause.

But when she took office, the issue was a dividing line. Some Republicans believed that the new governor couldn't be allowed another win after she had already achieved two of her three major campaign issues: reforming school financing and child welfare programs.

Four Republican leaders — Senate President Susan Wagle, Senate Majority Leader Jim Denning, House Speaker Ron Ryckman and House Majority Leader Rep. Dan Hawkins — have stood in her way.

Hawkins argued the plan is too expensive and those benefiting are able-bodied people who don't need the services and would edge out people who truly do.

Currently, Kansas provides Medicaid to specific groups of vulnerable people, including those who are disabled, over 65, pregnant or raising children. Under the ACA's Medicaid expansion, states can offer coverage for other residents making up to 138% of the federal poverty level (a little more than $17,000 for an individual or about $35,500 for a family of four). The federal government will pick up at least 90% of the cost of that coverage, a significantly higher match than it gives states for the traditional Medicaid program.

Such expansion in Kansas would cost the state about $47.4 million more the first year after adjusting for government funding and other offsets, according to the nonpartisan Kansas Health Institute. Advocates said that expense would be offset even further by the jobs created and health costs saved. Republican leaders argued it would prove much more costly, pointing to other states that were part of the initial wave of Medicaid expansion that underestimated the expense.

"The divide is, we now have a society that wants to move to 'the government provides everything,'" said Hawkins, who calls himself Medicaid expansion's "biggest detractor who hopes to stop the abomination of Obamacare."

Said Dr. Lee Norman, Kansas' secretary of health: "A lot of people don't like the Affordable Care Act, they've never liked it, and anything that's emanated from it is by definition 'evil' and people will look for any reason to besmirch it."

In reaction to the Republican leaders' obstruction, Democrats and moderate Republicans of the House staged what amounted to a coup against Hawkins by maneuvering to get Medicaid expansion into a bill by overruling the rules committee to push it through to the Senate. There it sat, never leaving the health committee.

By the end of March, four massive banners emblazoned with the four Republican leaders' names in red paint and the words "Blood on their hands" and "Expand Medicaid" were unfurled, hanging down inside the Capitol dome. They were up for only a few minutes before security officers ripped them down. Three Kansas State University students responsible for hoisting them were temporarily banned from the Capitol.

It was the kind of spectacle Kansas had not seen before in the Statehouse. And frustrated advocates cranked up the drama as the bill continued to sit. In May, they dropped thousands of leaflets covered with what looked like blood splatter depicting past-due hospital bills. The flyers, which included photos of the obstructing Republican senators, also stated that Kansas residents would die without expansion.

Hawkins denounced the advocacy, decrying tactics "you see on the coasts" in play by the "left" in Kansas.

Against that backdrop, the Democratic leader in the Senate attempted to bypass the stalemate with a procedural vote that would have forced the House bill onto the Senate floor. It needed 24 of the 40 senators. They got 23 — with Denning voting "pass."

Stymied, But Not Defeated

Moderate House Republicans and Democrats made a last-minute attempt to hold the budget hostage in order to guarantee Senate action on Medicaid. During negotiations, they relented after accepting the promise that an interim committee would work on a Medicaid expansion proposal for the next session.

As the committee gears up for a new debate, advocates and lawmakers worry that Republican leaders are planning to propose changes to the House bill that will ensure its failure.

Denning, the Senate majority leader, said he will offer a proposal to provide "health care coverage and affordable health care premiums to as many Kansans as we can" that contains work requirements — despite a federal judge barring such provisions in three other states. He will also seek federal approval for an expansion that would initially try to cover only those people whose family incomes were 100% or less of the federal poverty line. Both the Obama and Trump administrations have refused to grant waivers that seek full funding for Medicaid expansions that do not cover the income range stipulated in the ACA.

As for the governor? She said work requirements are a "non-starter."

When asked about whether she would accept an expansion on Denning's terms next year, Kelly pointed out she won his district by 20 percentage points.

"It's because I am more representative of his district," she said. "I am optimistic. You need to remember, it's an election year."