Medicaid expansion won’t be getting its day in the Kansas Legislature. Senators fail to put it to a vote

Doctors diagnosed Kelsey Vetter with a mild form of cerebral palsy before she turned 3 years old.

She hasn’t seen a doctor about it in more than a decade.

“That weighs on me every day,” she said. “I know I need to get myself checked out. … But I’m afraid of those medical bills piling up.”

Since the 38-year-old aged out of her parents’ health insurance plan, she hasn’t had any medical coverage. (Her cerebral palsy affects her balance and coordination, but not enough to qualify for disability.)

Vetter has worked retail jobs, part-time positions and contract grant writing. But none of that work has come with health insurance.

Like an estimated 100,000 other Kansas adults, Vetter falls into an insurance gap that stretches between Medicaid and the private coverage available through the Affordable Care Act.

She’ll watch closely this week as lawmakers in Topeka may finally debate a plan to expand KanCare, the state’s Medicaid coverage.

“I’m not looking for a free ticket,” said Vetter, who lives in Lenexa. “I’m looking for a boost. And I know Kansas is in the position of being able to look after its citizens.”

Understanding the gap

Kansas remains one of only 10 states that haven’t expanded Medicaid coverage to close the insurance coverage gap that Vetter and others fall into.

To get Medicaid in Kansas today, someone has to be a parent or guardian with an income below 38% of the federal poverty level. That means a family of four making even a penny more than $11,856 a year misses out. And a single person without a disability or who isn’t pregnant wouldn’t qualify, no matter their income.

That effectively leaves thousands of people without coverage, because the Affordable Care Act only covers people with incomes that reach at least the federal poverty level — about $15,000 as a single person or about $31,000 as a family of four.

People who make less than 100% of the poverty level but more than Kansas’ threshold for Medicaid are left with few options.

Originally, the Affordable Care Act included a provision for all states to make people below 138% of the poverty level eligible for Medicaid. But the U.S. Supreme Court struck down that part of the law in 2012.

Ever since, states have slowly been adopting it or “expanding” Medicaid.

The fight for Medicaid in Kansas

While Democratic Kansas Gov. Laura Kelly has pushed lawmakers to pass Medicaid expansion for years — and spent the last few months traveling the state campaigning for it — the Republican-led legislature has declined to bring the matter up for debate.

That changed in March, when the House Committee on Health and Human Services held a hearing that attracted a standing-room-only crowd and written testimony in support of the bill from 450 people. The Senate received testimony from 463 people.

The House committee declined to vote its bill out of committee, but in a late-night session earlier this month, Senate Minority Leader Dinah Sykes introduced a motion to bring the Senate bill to the floor for consideration, something Republican leaders have never allowed.

Today, Senators voted 18-17 to take the bill to the floor for debate. But that wasn’t the 24 votes needed to get it there.

In comments before the procedural vote, Sen. Mary Ware, a Wichita Democrat, said the failure to even debate the bill “indicates a state of mind.”

“Kansans have waited for over a decade for what should have been a slam dunk, obvious choice,” she said. “I’m very much in favor of Medicaid expansion.”

But the most important support — the support the bill needs to get through the legislature — is missing.

The state’s top Republicans oppose the bill, most often giving the same general objections.

They say Medicaid expansion will cost too much. They argue it will give coverage to too many “able-bodied adults.” And they worry that expanding Medicaid will take away private insurance coverage that some Kansans already have.

Proponents of Medicaid expansion point to research and other states’ experiences to counter these claims, and say Medicaid expansion can improve health outcomes, save struggling rural hospitals and bring new jobs and revenue to the state.

Justin Gust, vice president of community engagement with El Centro Inc., a Kansas City, Kansas, social service and advocacy organization, said he just wants lawmakers to have the debate.

“If we’re not ever getting to the point where we can talk about these things,” he said, “we’re really doing a disservice — especially to the Kansans who could get coverage if the legislation passed.”

Cost of Medicaid expansion

The Kansas Health Institute, a nonpartisan health research organization, estimates that the net cost of Medicaid expansion to Kansas over 10 years would be $171 million. That takes into account state costs, new revenue to the state — like managed-care fees and drug rebates — and money that’s coming from the federal government.

For people who get Medicaid coverage through the expanded part of the program, the federal government will chip in 90% of the cost, compared to about 62% the feds pay for existing Medicaid patients. That percentage varies by state. The federal government would also kick in an additional $500 million as an incentive offered through pandemic relief money.

In testimony before the House committee in March, Dean Clancy, senior health policy fellow with the conservative anti-tax Americans for Prosperity, said federal subsidies are unreliable and the program will be too expensive. He listed 15 reasons to oppose Medicaid expansion, but he said the top one was that it would cost “more than even the highest estimate you hear from experts.”

But that hasn’t been the case in the 40 states that have already expanded Medicaid, said Laura Harker, a senior policy analyst with the Center on Budget and Policy Priorities , who studies the issue.

“We haven’t seen budgets bust because of Medicaid expansion,” she said.

She added that the 90% federal match is enshrined in the Affordable Care Act and not expected to change.

States do take on costs when they pass expansion, Harker said. But they also reap savings.

States could benefit financially by shifting some coverage from the regular Medicaid pool to the expansion pool, for example. This might include someone who becomes pregnant and would have qualified for Medicaid before expansion. But, after expansion, she can be covered In the expansion pool. That, in turn, means the state’s share for care drops to 10%.

After expansion, Medicaid also covers the cost of caring for more jail and prison inmates.

Medicaid expansion states also see uncompensated care that hospitals have to pay for decline. If an uninsured patient gets Medicaid coverage, they won’t show up at a hospital emergency room for free care.

And, more generally, when people have better access to health care, they’re more likely to go to a doctor and prevent more serious, and expensive, problems.

Of course, those may be harder savings to quantify, but experts said if people are healthier they contribute more to the economy. And decreasing the amount of care that providers must write off creates healthier hospitals. That may be especially important in rural areas where hospitals are struggling to survive.

Dr. Doug Gruenbacher, a family practice doctor in Quinter, testified that expanding Medicaid “is about supporting our rural hospitals and keeping physicians in Kansas by approving a business model that isn’t depleted by uncompensated care from the outset.”

In Missouri, where voters adopted a constitutional amendment that led to Medicaid expansion in 2021, emergency department visits paid for by Medicaid increased almost 15% at the end of 2022 compared to the beginning of 2020, according to an analysis from the Center for Advancing Health Services, Policy and Economics Research at Washington University in St. Louis. During the same period, uninsured visits dropped by 14%.

That’s the trend Swope Health in Kansas City has seen, too, said CEO Jeron Ravin. After Missouri implemented Medicaid expansion, Swope, which has clinics on both sides of the state line, saw its uninsured rate decline to around 35% from close to 50%.

“It was a pretty big jump,” Ravin said.

He said that Swope also is seeing its patient numbers climb and has increased its payroll to around 600 employees from 516 before expansion.

“Some of those numbers are being driven by folks having access (to health care) who didn’t,” he said. “We’re seeing more patients, we’re providing more services and we’re stronger financially.’”

How many Kansans will get coverage?

But opponents of Medicaid expansion in Kansas believe that the state can’t afford it, no matter the benefits. And they worry that the number of new Medicaid recipients who may enroll will be more than the state can handle.

The Kansas Health Institute estimates that 106,450 adults and 45,448 children would enroll in KanCare after expansion. But enrollment estimates in other states have proved to be too modest.

Missouri anticipated about 250,000 new enrollees before expansion passed, but reported about 300,000 adult expansion enrollees this month. The state’s expansion coincided with COVID, which also contributed to the increased enrollment.

In Kansas, opponents argue that Medicaid dollars should be saved for the state’s most vulnerable citizens, not made available to “able-bodied adults” who they contend could get insurance through a job.

“Kansas is wise to preserve limited Medicaid funds for the truly vulnerable for whom Medicaid was originally designed,” state Sen. Beverly Gossage, a Eudora Republican, told the House committee in testimony.

Gossage, who has spent her career as a health insurance agent, also said that Kanasans who make between 100% and 138% of the poverty level and currently get private coverage through the insurance marketplace would be forced to pay more or switch to Medicaid if expansion passes.

“Has anyone thought to ask these folks how they would feel about being forced by their legislators to go on Medicaid and likely give up their doctor and private plan that they had?” she said.

She told the committee that legislators should instead focus on removing obstacles that discourage people from getting a job.

But the Kansas Health Institute estimates that 69% of 19- to 64-year-olds likely eligible for coverage if Medicaid is expanded are working.

And that’s what Andrea Perdomo-Morales, chief health equity officer with Vibrant Health, a community health clinic in Wyandotte County, sees among the patients she works with who fall in the insurance gap.

“Many individuals are working not only one job,” she said, “but multiple jobs to make ends meet.”

Covering them under Medicaid won’t take them out of the workforce, Perdomo-Morales said. It will keep them there by keeping them healthy.

Vetter said she wants lawmakers to know that she’s not asking for a handout, but she also knows she needs regular checkups, teeth cleanings and cancer screenings.

“If those needs are met,” she said, “I will continue to find work and I will pay taxes.”

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