As lawmakers in a nearby hearing room debated last month whether to support her Medicaid expansion legislation, Kansas Gov. Laura Kelly dared the state’s Republican Speaker of the House to hold a vote.
“If he thinks he can kill it, bring it on,” Ms. Kelly, a moderate Democrat, said in an interview in her sprawling suite of offices at the State Capitol in Topeka.
The next morning, in his office off the House floor, Speaker Dan Hawkins showed no signs of backing down. He described the Medicaid expansion as “almost like the biggest Ponzi scheme ever devised.” That same day, a House committee voted against sending Ms. Kelly’s bill to the floor, derailing the proposal — at least for now.
The showdown between Ms. Kelly and Mr. Hawkins represented a fight in a bitter political battle being fought in several state capitals over the future of Medicaid, the health insurance program for the poor. In Kansas and some Republican-controlled Southern states, supporters of the Affordable Care Act expansion have renewed efforts to overcome longtime Republican opposition, creating a sense of progress.
But neither Ms. Kelly nor Medicaid expansion advocates elsewhere have been able to advance the legislation long 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 they deserve it.
“It’s really the fundamental moral question of where the safety net should be,” said Ty Masterson, the Republican president of the Kansas Senate and a longtime opponent of the expansion. “And the safety net should be for the weak and the elderly and 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 the debate over the program’s future unfolds with the 2024 presidential campaign as scenery.
In his campaign for re-election, President Biden highlighted his administration’s work to preserve the Affordable Care Act. Former President Donald J. Trump, the presumptive Republican nominee, has threatened the health care law in recent months, without detailing his own plans on the matter. Health experts said a second Trump administration could push to defund Medicaid or allow states to limit the amount of money they spend on the program.
Kansas is one of only 10 states that has 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, meet the requirements for the program. All of Kansas’ neighbors have adopted the expansion, three of them — Missouri, Nebraska and Oklahoma — through ballot initiatives in recent years.
Those who qualify for KanCare, as the Kansas Medicaid program is known, include children, parents, pregnant women and the disabled. The income threshold 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’s 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.
Ms. Kelly and other supporters of Medicaid expansion in Kansas have been pressing their case for years. In 2017, the Legislature passed a bill to expand the program, but it was vetoed by the Republican governor at the time, Sam Brownback. Ms. Kelly, who was then a state senator, campaigned on Medicaid expansion in her successful bid for governor the following year and her bid for re-election in 2022.
In her latest attempt to persuade lawmakers to compromise on the expansion, Ms. Kelly changed her approach. He unveiled an extension bill in December that includes a work requirement, offering Republicans a concession he believed could win them over.
“I tried everything else and it didn’t work,” he said. “I wanted to take that off the table as an excuse.”
At the state Capitol last month, House and Senate lawmakers held two hearings on the Medicaid expansion — the first on the issue in four years, giving supporters of the legislation a sense of progress. Both hearing rooms were so packed that guests were forced to listen from the corridors or testify in overflow rooms.
There were also signs of movement in Republican-held Southern states. In recent months, Republican leaders in Alabama, Georgia and Mississippi have expressed renewed openness to Medicaid expansion. House and Senate lawmakers in Mississippi have approved different Medicaid expansion plans in recent weeks despite intense lobbying by the state’s Republican governor, Tate Reeves, who has vowed to veto any bill that reaches his desk.
“There is momentum,” Ms Kelly said.
There were also setbacks. On the same day that lawmakers in Topeka blocked Ms. Kelly’s bill from advancing to the floor, a similar measure in Georgia died in a Senate committee. Mr. Masterson, the Kansas Senate president, argued that the resistance in his state and elsewhere showed that momentum was going in the opposite direction.
Mr. Masterson and other opponents of Medicaid expansion have argued that the long-term cost to state budgets is too severe. Supporters said the financial rationale is obvious, with the federal government covering 90 percent of the cost. A 2021 pandemic relief package sweetens the deal even more for states that have not yet expanded.
Ms. Kelly said the expansion will benefit the Kansas economy and create thousands of health-related jobs. Officials from hospitals and community clinics in the state see the expansion as a potential lifeline for rural providers under financial pressure.
Benjamin Anderson, the 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 shouldering the costs of care for the uninsured had convinced 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 Mr. Hawkins, who previously owned a health insurance agency, rejected the idea that Ms. Kelly’s bill, with its work requirement, could sway voters. Regardless of the legislation, he said, the expansion would swell the state budget and ask taxpayers to pay for the medical needs of healthy adults who could be working and on employer or marketplace plans.
“We’re all supposed to provide them with something they don’t even care about so they can go to work and get it?” asked Mr. Hawkins. “What happened to our idea in this society that we should support ourselves, especially if we are able?”
The Kansas Institute of Health, a nonpartisan research group, has estimated that about 70 percent of those who could become eligible for Medicaid under expansion are working.
One of those who could potentially qualify is Stephen Zook, an uninsured restaurant server in rural Buhler, Kan., who makes about $15,000 each year and falls into the Kansas coverage gap. He said he hasn’t been able to see a therapist for depression and other mental health needs and hasn’t been able to pay a nearly $2,000 medical bill he received for a heart implant last year.
“It’s certainly not people who are lazy,” he said. “They are people trying to make their lives better for themselves. I try to pull on my boots as often as I can. And it’s still not enough to get the coverage I need.”
Melissa Dodge, a single mother of four in Derby, Kan., who works part-time as a restaurant hostess and is also stuck in the coverage gap, said she struggled to make ends meet as she took care of her daughter’s complex medical needs. and daily tasks such as dropping off school.
Her doctor is careful not to order lab tests because of the potentially prohibitive cost, Ms. Dodge said.
“It’s a huge source of stress,” she said of not having health insurance. “There is a fear that I refuse to allow to run my life. But it’s there. And I can’t help but recognize that.”
Mr. Hawkins acknowledged that the politics of the Affordable Care Act had shifted as Republican opposition to the law waned, leaving it a less powerful issue to campaign on. “I just don’t think it packs the punch it once did,” he said.
Ms. Kelly said that if expansion supporters fail in the current legislative session, they will try the issue on the campaign trail this year. “This is going to be the No. 1 election issue,” he said.
Ms Kelly predicted that opponents of the expansion were fighting a losing battle.
“They’ve painted themselves into a corner,” he said. “And I think they’re having a hard time finding a face-saving way to get out.”
