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Kansas leaders have failed in attempts to expand Medicaid. Will Congress do it for them?

September 29, 2021

For nearly a decade, politicians in Kansas have sought to expand access to Medicaid only to be blocked by conservative Republicans.

Gov. Sam Brownback vetoed a bi-partisan effort in 2017, citing the lack of work requirements for beneficiaries and a failure to defund Planned Parenthood. Senate President Susan Wagle scuttled another bi-partisan agreement in 2020, making passage contingent on approval of an anti-abortion constitutional amendment.

Now, Democrats in Washington, D.C. are on the verge of stepping in.

"State after state has chosen to expand Medicaid and protect the health of their most vulnerable residents, but Kansans continue to suffer solely because partisan actors have repeatedly chosen to leave money on the table," said Kansas U.S. Rep. Sharice Davids. "Kansans have made their voices clear on this — that's why we are exploring every avenue, including continued financial incentives for states and a federal option to close the Medicaid coverage gap."

Among the many provisions in the mammoth budget bill Democrats are calling "Build Back Better" is a new Medicaid program to provide health insurance for most low-income adults in the 12 states, like Kansas, that have not expanded eligibility for coverage. The expansion, a provision of the 2010 Affordable Care Act, would cover households making up to 138 percent of the federal poverty line, or $36,570 for a family of four.

It may be the only shot to extend coverage to the estimated 165,000 Kansans who don't have health insurance. The latest efforts to expand Medicaid have attracted little support in Topeka.

"I don't think it's in the cards in this building for 2022," State Sen. Pat Pettey, a Kansas City, Kansas Democrat said in Topeka last week. "We haven't been able as a Legislature to even have, I would say within the last 2 years, to even have a significant conversation about Medicaid expansion."

Any federal Medicaid expansion relies on Democrats agreeing to pass a budget bill packed with legislative priorities, from universal pre-kindergarten to combating climate change. The status of the package is tenuous. Conservative Democrats in the Senate have chafed at the $3.5 trillion cost, and House and Senate Democrats are negotiating what portions to cut.

Some of the bill's healthcare provisions have been part of the negotiations, such as whether to allow Medicare to negotiate drug prices with pharmaceutical companies, another measure supported by Davids. The provision creating a federal Medicaid program for people in the "coverage gap," however, has stayed uncontroversial.

If the provision remains and the bill becomes law, the Secretary of the Department of Health and Human Services would have until 2025 to create a new program to administer Medicaid to the newly eligible recipients.

Until the program is set up, they would be able to get subsidies to purchase coverage in the federal health insurance marketplace.

Depending on how the program is set up, the federal workaround means the state potentially would not have to spend any money on insurance coverage for the expanded Medicaid population — even though the federal government covers 90 percent of the cost for states that have expanded.

But it also means they won't get any say over running the program and how to best tailor it for Kansas.

"It would be great to have those people insured but we do lose the opportunity to make it a Kansas program, to put our own stamp on things," said Kansas state Rep. Susan Concannon, a Beloit Republican who supports Medicaid expansion.

Expansion proponents said they would still like to see the Kansas legislature pass a bill. April Hollman, Executive Director of the Alliance for a Healthy Kansas, said she would like to see a program tailored to the needs of Kansas, which would require expansion by the legislature instead of a federal workaround.

Concannon said she hoped the state's lack of control over the workaround would encourage conservatives who have resisted expansion to come to the negotiating table.

A federal program may not have work requirements, which some conservatives have made a condition of expansion. The 2020 version of the bill crafted by Kelly and Senate Republican leader Jim Denning had a program that referred people to work, but didn't require it.

Still, the prospect of the federal government stepping in doesn't appear to have changed the minds of Republicans who opposed Medicaid expansion. Sen. Richard Hilderbrand, a Galena Republican and chair of the Senate Health and Human Services Committee, called it federal overreach and promised to seek ways to fight if it goes through.

"The federal government is stepping way outside of its intent of what the founding fathers wanted it to be," Hilderbrand said. "We don't need any more federal programs and if it's a state issue like it always has been let the states decide if they want it or they don't.