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Kansas elections set up hidden referendum on Medicaid expansion

Voters in Oklahoma and Missouri directly made the call on whether to expand government financed health insurance in their states. But that can’t happen in Kansas. Instead, the fate of a long-debated, deadlocked Medicaid expansion proposal can only be made in the traditional manner: on the basis of which legislators are chosen on Nov. 3.

 

David Larson was alarmed in June when he started feeling sick. The coronavirus was spreading in Kansas, and the 56-year-old Wichita resident – who lives with diabetes, high blood pressure and clinical depression – knew his preexisting conditions made him vulnerable to the illness.

“I came down with something. I was nervous it might be COVID,” he says a few months after recovering. “It was actually the flu.”

Larson wasn’t just worried about his health: He also was unsure how to pay for the cost of getting well. He last had health insurance in 2010, losing it when he stepped away from his job as an ordained minister after coming out of the closet. Since then, he worked a part-time job with the National Alliance on Mental Illness-Wichita chapter to pay the bills – but didn’t make enough to buy his own insurance. For the most part, Larson managed his chronic conditions with visits to the Guadalupe Clinic, a nonprofit health center, and Comcare Sedgwick County.

The possibility of COVID-19, though, was a more urgent matter.

In this case, a friend stepped in to help – taking Larson to the doctor and paying an upfront cost of $189 for an office visit, along with the resulting Tamiflu prescription.

“It was nice having my friend do that,” he says, “but if he hadn’t done that, I would’ve floundered and gotten through to the other side wondering what it is I had.”

In many other states, Larson might have qualified for Medicaid, the program that uses a mix of federal and state dollars to provide health insurance to low-income residents.

In Kansas, though, eligibility is largely restricted to children, pregnant women and adult parents of children under the age of 19. Larson, who is unmarried and has no children, doesn’t qualify.

“I am single,” he says, “and I fall through the cracks here in Kansas.”

In recent years, elected officials have been locked in a debate over whether – and how – to expand Medicaid to include people like Larson, as well as many of the estimated 150,000 Kansans who fall into the health insurance gap: They earn too much money to qualify for KanCare, the state’s version of Medicaid, but not enough to buy their own insurance or to be eligible for subsidized coverage on the Affordable Care Act marketplace.

That debate will surely continue. But the conditions surrounding the topic have changed – the pandemic and accompanying recession have refocused how Kansas serves its poorer residents while badly straining state finances. Increasingly, the state is alone even among its conservative neighbors, after voters in Oklahoma and Missouri recently approved Medicaid expansion in their states.

Nearly 70% of nonelderly adults secure insurance through an employer, according to the Kansas Health Institute’s 2020 report on insurance in Kansas. Another 8% buy coverage directly, while 10.4% are on public coverage programs. About 12.3%, approximately 206,000 people, are uninsured.

Most uninsured adults in Kansas are white, but Hispanics of any race are the most likely to be uninsured. Although Hispanics account for an estimated 12% of the state’s population, they make up nearly 31% of the uninsured population.

Medicaid expansion wouldn’t be a cure-all, but it would likely significantly reduce the ranks of the uninsured. According to the health institute, about four-in-10 uninsured Kansans could qualify for Medicaid if lawmakers expanded eligibility. Back in January, the institute estimated that 93,000 adults and 39,000 children would newly enroll in KanCare under expansion. About 77,000 of those enrollees would be people without insurance, but about 55,000 would be expected to shift to KanCare from other coverage.

In a sense, Kansas voters and the lawmakers they elect face choices about how to use the levers of government to promote health, which some argue should be a basic human right. Do voters support broadening the government’s role in providing health insurance coverage to reduce the numbers of people who fall between the cracks, while at the same time slightly decreasing the percentage of people privately insured?

One way to frame the debate is a choice between competing values, one of expanding coverage through government intervention, the other of preserving the private sector’s role in the system through maintaining existing limits on government. Another would be deciding whether to prioritize government resources on reducing the coverage gap versus spending it in other areas.

Meanwhile, the Medicaid expansion debate leaves a broader set of health care-related quandaries, from affordability to price transparency, on the back burner. Until the Legislature brings resolution to the Medicaid expansion debate, it’s difficult for the factions involved to view or act on daunting health care issues through any other lens.

Voters have the power to resolve the issue based on which candidates they send to Topeka for the January 2021 legislative session. But their choice is much less clear-cut than in states where the issue has been decided by referendum, because they’re likely to be weighing a variety of issues and factors while casting their ballots. In a state where most Kansans have private health insurance through their employer, how concerned are the privately insured about those who go without or whether government offers health insurance to more people?

Opponents of Medicaid expansion say there are better ways to expand access to and increase the affordability of medical care.

“In Kansas, people don’t necessarily see government as the most effective way to solve all the problems all the time,” says Elizabeth Patton, deputy state director of the Kansas chapter of Americans for Prosperity.

Backers of expansion, though, think they just need to push a little harder.

“We are still very hopeful – because this is an important issue for people across the state – that even with the odds stacked against us, we’ll be able to make something innovative happen just from the sheer force of will from Kansans behind this,” says April Holman, executive director of Alliance for a Healthy Kansas.

(Disclosure: The Kansas Health Foundation, which funds the Kansas Leadership Center, publisher of The Journal, has also funded the Alliance for a Healthy Kansas. As a 501(c)3 educational organization, KLC does not take positions for or against issues.)

Can the deadlock be broken? And what does it say about Kansas that wrangling continues while most other states have addressed the issue and moved on?

“A lot of folks would’ve predicted it might’ve gotten there,” says Kari Bruffett, vice president for policy at the Kansas Health Institute, which takes no position on the issue. “The outcome of the elections in the fall will determine the tone of the debate, as well as the outcome.”

 

Kelsi Depew would benefit from Medicaid expansion in Kansas.

Kelsi Depew’s family epitomizes the patchwork nature of health insurance coverage in Kansas. Her children have coverage through KanCare. Her husband has insurance through his job. Although Kelsi could be added to her husband’s policy, it’s cost prohibitive for the family.

 

TWISTS AND TURNS

Congress passed the Patient Protection and Affordable Care Act – popularly known as “Obamacare” – in 2010. The legislation included provisions to expand Medicaid in all 50 states to cover all individuals with an income of up to 138% of the poverty line. In 2012, the U.S. Supreme Court ruled that the federal government could not require states to expand their Medicaid coverage. Instead, each state could choose whether or not to opt-in. They had at least one incentive for doing so: Since 2016, the federal government has paid 90% of each state’s costs for the expanded coverage.

Thirty-nine states have OK’d Medicaid expansion. Kansas remains one of the exceptions.

There have been some close calls. In 2017, the Legislature passed a bill approving expansion; then-Gov. Sam Brownback used his veto, saying any expansion would have to have a neutral impact on the state budget, as well as include a work requirement for eligibility. He also objected to the possibility that abortion providers would receive tax money under the program.

In 2018, Democrat Laura Kelly won the governor’s race while campaigning in part on a promise to expand Medicaid. “2018 was a hopeful year,” Holman says. 

New obstacles appeared, however. During the 2019 session, the House passed a bill approving expansion. An effort to bring the bill to the Senate for action mustered 23 of 40 votes – but 24 votes were required.

During the 2020 session, Kelly and Senate Majority Leader Jim Denning, an Overland Park Republican, announced a compromise. “It’s a lot easier to get to no than it is to get to yes, but this is what governing looks like,” Denning said at the time.

Senate President Susan Wagle, a Wichita Republican, accused Denning of betraying his Republican colleagues and intertwined the fate of Medicaid expansion with approval of a constitutional amendment reasserting the Legislature’s power to restrict abortion. The result was a standoff. Denning announced in May he would retire from the Legislature, seemingly wearied by the battle. 

“Unfortunately,” Denning wrote in his retirement letter, “I have seen too much hyper partisan gamesmanship and we should not allow partisanship to continue in this pattern.”

The inability of the state’s leaders to find resolution on Medicaid expansion might seem baffling – after all, there seems to be widespread support from voters. A most recent Kansas Speaks survey by Fort Hays State University, in 2019, showed that 62% of respondents favored expansion. Just 23% were opposed. (The 2020 version of the poll lists support at nearly 64% and opposition at nearly 16%.)

The failure to pass a bill “is not a reflection of the will of people of Kansas,” Holman says.

But GOP opponents of expansion are skeptical the program is really that popular, especially if voters understand that the existing Medicaid program covers children, pregnant women, people with disabilities and the elderly. A month before the Kansas Speaks poll was made public, Kansas House Majority Leader Dan Hawkins, a Wichita Republican, commissioned his own poll of 550 registered Republicans – he said 75 percent opposed expanding Medicaid to cover “able-bodied adults.” He circulated the poll to his fellow Republicans.

The most prominent opponents of Medicaid expansion, however, tend to emphasize other objections – mostly the program’s cost and effectiveness.

“The core thing both sides want to see out of this – the goal is we want to see greater access to care at more affordable cost,” says AFP’s Patton. “ I just think it comes down to two very different perspectives on how to accomplish that.”

While the state’s leaders debate the issue, though, some Kansans are struggling to get by and stay healthy without reliable health insurance.

 

WHEN THE PLAN DOESN’T WORK OUT

Kelsi Depew, 31, got married a decade ago to a co-worker at a wheat research firm in Reno County. Both had health insurance. They decided to commit to their future by starting a family and buying a house.

“We had money set aside and had a game plan,” Depew said.

While she was pregnant with her first daughter, though, the company pulled up roots and left the state. The couple was suddenly stuck looking for work, and for health insurance. Depew’s husband started cutting firewood to earn money – and because she was expecting a child, Depew was able to get covered under KanCare. Fourteen months after her first child was born, she gave birth to twin girls.

The children are covered under KanCare. And Depew’s husband can get health insurance through his current job with the Postal Service. But the family can’t afford to expand that coverage to include Kelsi, or they wouldn’t be able to pay the bills.

“It was way too much,” she says. ”It was 60% of our income to provide both John and I with insurance. That wasn’t doable.”

The family has gotten by through a mix of resourcefulness and good fortune – “luck and genetics,” Depew says. “Between my husband and I we have gotten lucky on a lot of things. I don’t have a chronic illness.”

She has learned to treat minor injuries and wait out spells of bad health. Once, when she had a strep infection, Depew waited until she could see spots on her throat before calling the doctor. And when she does need a doctor’s help, she tries to call ahead to see what the noninsured cost of a visit will be.

“They usually don’t know,” she says. “Usually it’s less if you pay that day. I try to plan ahead so we have money to go that day.”

Depew is glad her daughters have coverage from the state but also acknowledged some mixed feelings on that front.

“My children have needed things,” she says. “My daughter needed a hip surgery. She has insurance, and however horrible it is she needs hip surgery, the financial and rational part of me is glad it’s not me. And that feels bad.”

Under the current system, Depew is unsure what more she and her family could do to obtain health coverage. She is frustrated.

“We’re really trying to do the best thing,” she says. “We work hard, we put money in savings accounts. We budget; we don’t overspend. But we just can’t get health insurance. It’s not an option.

“I don’t know what people expect us to do.”

 

A look at the Kansas insurance coverage mix.

 

THE CHANGING TERMS OF THE DEBATE

The opponents of Medicaid expansion mostly make a two-pronged argument. First, they say, expansion would be too expensive – even if the federal government covers most of the costs.

“The actual costs come in much higher than the estimates,” says Alan Cobb, president and CEO of the Kansas Chamber of Commerce. “We’re going to be in a fiscal crunch because of the downturn – what are you going to take away from?”

State Sen. Gene Suellentrop, a Wichita Republican and chairman of the Senate Public Health and Welfare Committee, agrees. “Some may say we need it more than ever. Well, now we can’t afford it more than ever,” he says. “We’ve got major budget issues to deal with the next two fiscal years.”

Opponents also contend that expanding Medicaid hasn’t been all that effective, pointing to a study of Oregon’s 2008 pre-ACA Medicaid expansion. Research published in The New England Journal of Medicine found no improvement on many health outcomes

“If we don’t think Medicaid works, why expand something that doesn’t work?” Cobb asks. “Medicaid is not health care, it’s a way to finance health care. Are we forgoing an opportunity to look at a way to deliver health care to those who don’t get it?”

Holman, from the Alliance for a Healthy Kansas, agrees that state legislators would have to carefully negotiate the fiscal impact of Medicaid expansion. The health institute estimated in 2019 that the program would cost the state $1.2 billion over 10 years, though new revenues and other offsets could reduce the bottom-line impact by half.

But she believes that by bringing federal dollars to Kansas, Medicaid expansion would have a positive effect on the state’s bottom line. (One study in May, released by The Commonwealth Fund, concluded that “the net impact on (state) general funds is much smaller than expansion’s costs. In some cases, Medicaid expansion more than pays for itself.”)

“There’s a multiplier effect. It will result in more economic activity, more increased tax revenues because of that activity,” Holman says. “It’s a lifeline that we desperately need now.”

Supporters of expansion cite research that Medicaid expansion has saved 19,000 lives in the states where it has passed. Studies of Oregon also found that patients experienced less financial strain and that medical bankruptcies were reduced. And, they argue, expansion would be a boon to rural communities where hospitals and other health care providers have struggled to survive in recent years.

“This is an answer to issues in all kinds of areas,” Holman says.

While these big-picture arguments matter, Bruffett of the health institute detects a shift in how state policymakers talk about the issue.

While these big-picture arguments matter, Bruffett of the health institute detects a shift in how state policymakers talk about the issue. Medicaid expansion bills in the last few years have gotten hung up not on whether to do expansion, but on details and seemingly tangential issues: How and whether to implement a work requirement with the program, or whether to pass an anti-abortion amendment to the Kansas Constitution.

The argument has been less about whether Kansas will expand Medicaid, Bruffett says, and more on what that expansion would look like.

 

Gov. Sam Brownback

The closest Kansas has gotten to expanding Medicare was in 2017, when legislation cleared the House and Senate but was vetoed by then Gov. Sam Brownback. The unsuccessful quest in many respects mirrors the nation’s inability to reach a consensus about the role of government in providing health care.

AN INTERIM FIX?

Larson and Depew, among others, are impatient for the debate to come to some kind of resolution.

“The issue is people, not politics,” Larson says. “There are people who are struggling and want insurance, need insurance. It’s a basic human right to have health care. It shouldn’t be a political issue, but it has become one, yes.”

Depew thinks political divisiveness has had the unfortunate effect of simplifying a complicated issue.

“I think it’s important to tell people that. They seem to think you feel one way or another,” she said. Instead, Depew said, the discussion of Medicaid expansion fits in a broader framework:

“I think what’s really wrong is the whole financial-medical system is very wonky. It’s not working right. I do view expansion as a little bit more of a temporary thing, as something that should be done in the meantime, while we’re working on this.”

Next year legislators will face a different political landscape than the one where they battled in recent years over Medicaid. The pandemic has caused a downturn in state finances, but it has also highlighted the potential need to ensure that poor Kansans – particularly low-income essential workers who have faced the dangers of COVID-19 without health insurance – have affordable access to care. And some observers suggest that voter referendums to approve expansion in Missouri and Oklahoma create additional pressure on Kansas leaders to fall in line.

“We’re out of step with the region and the people in our state,” Holman says.

Others, though, point out that Kansas doesn’t have a referendum process.

“We don’t operate that way, so it’s not going to happen,” Suellentrop said of the referendums. “You need to have a majority or a supermajority to get it passed” in the Legislature. “It takes the votes to get it passed.”

Holman says her group will focus during the next session on rededicating itself to grassroots organizing on the issue – particularly in rural communities. “I really think as we look at the upcoming year, we’re focusing more than ever on public education and organizing in key communities across Kansas,” she says. “I think we need to have more personal connections with people in local communities … so they are dug in with us and in the trenches.”

That may or may not make a difference.

Suellentrop said Medicaid expansion is one of many issues – education funding being a big one – that will occupy the Legislature in 2021. And he expects that after the election, conservative Republicans, who won big in the August primaries, may be even better positioned to resist advancing a Medicaid expansion bill.

“There’s a strong possibility there will be even less support in the Legislature,” he says.

 

BENEFITS OF A ROBUST DEBATE

Some observers say Kansans shouldn’t be discouraged by the gridlock on Medicaid expansion.

“I don’t think there’s much of a robust debate in the states where it passed,” Cobb says. “I can make a case Kansas is doing a better job of critical thinking about health care.”

Patton agrees. Even in states where Medicaid expansion has passed, she says, the debate isn’t really over. “The conversation still hasn’t ended in those states – they have provider issues or budget issues,” she says. Instead, she says, state leaders should look at alternative methods of expanding inexpensive access to health care, such as permanent approval for telehealth services in Kansas and letting groups of self-employed workers band together to form associated health plans. Medicaid expansion, she says, isn’t a silver bullet. “Let’s find an actual solution.”

Holman, however, is hopeful the upcoming session will be the one in which Medicaid expansion finally passes. Despite hints that conservative opponents will be strengthened by the coming election, “we still anticipate we’ll have a majority in the House and Senate that support Medicaid expansion.”

She expects to prevail sooner or later.

“I think Kansans have traditionally prided themselves on having good infrastructure – good schools, good roads – and Medicaid expansion is part of the infrastructure we need to build up in Kansas,” Holman says.

In the meantime, Kansans like Larson and Depew wait, and contemplate how their lives might change if they had Medicaid coverage – or better, affordable health insurance of any kind.

“I would have to say that with insurance I would be able to get my meds filled in a timely manner,” Larson says. “I would not feel fear of going to see the doctor. And I wouldn’t have as much fear of the coronavirus.”

“I would participate in more traditional preventative care,” Depew says. “I would go in for a regular well-visit to check on things. I wouldn’t worry quite as much about a medical emergency or onset of a chronic illness. At least, not worry in the same way I do now.

“I view it as something about valuing people. And I’m feeling undervalued.”

Bruffett, however, suggests that instead of focusing on what hasn’t been accomplished,

Kansans should look at how the debate continues to evolve and how the state might still eventually chart a final course on the matter.

“I think it’s sometimes tempting to look at other states and compare, and policymakers like to do that, but this is a Kansas debate,” she says. “I think the flow, the evolution is still moving.”

A discussion question

 

 

A version of this article appears in the Fall 2020 issue of The Journal, a publication of the Kansas Leadership Center. To learn more about KLC, visit http://kansasleadershipcenter.org. Order your copy of the magazine at the KLC Store or subscribe to the print edition.

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