The panel featured Kansas Senate Majority Leader Jim Denning, Kansas Secretary of Health and the Environment Dr. Lee Norman, researcher and professor at the University of Kansas Dr. David Slusky, and president of the Bluford Healthcare Leadership Institute Dr. John Bluford. The discussion was moderated by William Jewell College’s Dr. Gary Armstrong.

American Public Square provided a program and a basic facts sheet to inform the audience. The panelists often referred to information provided on the fact sheet during the discussion. 

Among the points discussed were the differences between Medicaid and expanded Medicaid, the Kansas bill for Medicaid expansion and how it would be funded, and how those on Medicaid would be affected by the expansion.

Denning explained that in Kansas, funding for traditional Medicaid comes in a constantly changing ratio of federal and state contributions. At the time of the panel, 60 percent of Medicaid was funded by the federal government and 40 percent was funded by the state. This is revised periodically. 

Funding for Medicaid expansion is different. Ninety percent of funding for the expanded program would come from the federal government, with only 10 percent coming from the state.

Denning also explained the sources of funding for Medicaid within the state. Traditional Medicaid is funded mostly out of the state checking account. About 13 percent comes from a tax on HMO insurance. The Kansas Legislature, specifically Denning, is attempting to find sources of funding for the expansion that would require no further draw upon state checking account funds. This would include a tax or surcharge on hospitals and a greater HMO tax. 

Panelists mentioned that states have already lost millions of dollars that could have been put toward Medicaid and healthcare programs by not expanding. 

Bluford argued that the human element of Medicaid and expansion is often overlooked. Most of the people who are on Medicaid would rather not have to be, and it provides care for those who otherwise could not afford it. However, it can be difficult to find doctors who take Medicaid because the payout is below cost for the treatment and can often come in payments months after treatment happens. This is a problem that needs to be fixed. Medicaid expansion would help narrow the gap and address this. 

Part two of a two-part series on Medicaid expansion in Kansas and Missouri. Part one can be found here.

Much like Kansas, Missouri is one of the 14 states that has yet to expand its Medicaid program under the provisions of the Affordable Care Act. While in Kansas the battle over Medicaid expansion has been a major battle in the state legislature, in Missouri the final decision may come down to the voters.

In Missouri, non-disabled adults are not eligible for Medicaid coverage, and parents are only eligible if they are making up to 22 percent of the federal poverty line. In Kansas, this cap is 38 percent of the federal poverty line. At 18 percent, only Texas and Alabama have a lower cap for Medicaid eligibility than Missouri. 

Under the Affordable Care Act, people making between 100 percent and 400 percent of the federal poverty line are eligible for subsidized private health insurance plans from the Federal government. Just like in Kansas, this means many people do not make enough money to qualify for subsidized private health plans but make too much money to qualify for Medicaid. A single parent making more than $2,892 a year but less than $16,910 a year falls into this gap and is ineligible for either Medicaid or subsidized private insurance. 

It is estimated that with Medicaid expansion in Missouri, which would raise the cap on Medicaid eligibility to those making up to 138 percent of the Federal poverty line and extend eligibility to adults without children, between 219,000 and 327,000 people would gain access to healthcare. 

The issue of Medicaid in Missouri was further complicated in August, when it was revealed approximately 120,000 Missourians were removed from the rolls for Medicaid registration between January 2018 and July 2019, the majority of them children. The reason for this drop in enrollment has led to a contentious partisan debate. 

Democrats have cried foul play and accuse Republican Governor Mike Parsons of standing by while Medicaid recipients are being removed from the program under questionable circumstances. On the other hand, Governor Parsons and Republicans in the State Legislature attributed the drop to an improvement in the state’s economy and better technology enabling auditing of recipients. This, coupled with recent cuts to the program, has made the issue all the more pressing for advocates.

Previous attempts to pass Medicaid Expansion in the Missouri General Assembly have failed to even be debated, and most died in committee. The most recent attempt during the 2019 session did not even receive a hearing.

“An ideological unwillingness of the majority party to consider the legislation which stems from what I believe is their fear that the expansion of Medicaid might result in their loss of a supermajority, if not the loss of the majority outright,” State Representative and William Jewell Alumnus Mark Ellebracht (D-Liberty) said attributing this failure to Republicans. 

With Republican supermajorities in both Houses of the General Assembly, and a Republican Governor, it is unlikely that Medicaid expansion will be passed by legislative means. As a result many advocates have turned to the ballot initiative system, hoping to put the issue before Missouri voters in 2020. 

In September the Healthcare for Missouri coalition launched a petition campaign to get Medicaid expansion on the ballot in 2020. 

“For years, we have worked with the Missouri legislature to expand Medicaid and health care options for our neighbors – but we can no longer wait on politicians to do the right thing,” according to a spokesperson for Missouri Jobs with Justice, one of the organizations involved in the Healthcare for Missouri coalition. 

 To get the issue on the ballot advocates will need to collect more than 170,000 signatures by May 3, 2020, and already have begun collecting signatures across the state. According to Missouri Jobs with Justice, over 16,000 signatures have already been collected from across the state. 

The campaign has also raised over $2.2 million to support its efforts, with large donations being made by the Kansas City-based Health Forward Foundation, BJC HealthCare in St. Louis, the Missouri Hospitals Association and the Sixteen Thirty Fund, a liberal non-profit group based in Washington D.C. 

This could prove to be a winning strategy. Previous ballot initiatives on Medicaid expansion have been successful in Maine in 2017, and in Utah, Idaho and Nebraska in 2018. With voters in other solid red states voting in favor of Medicaid expansion, Missouri stands a good chance of following suit next fall. This is further supported by other ballot initiatives in Missouri, such as the failure of Proposition A, and the success of the Clean Missouri ballot initiative and the Minimum wage increase passed by Missouri voters in 2018.

“I am optimistic that the voters of the State of Missouri will do what is in their best interest, as they did on Proposition A and increasing the minimum wage,” Ellebracht said.

While the fate of Medicaid expansion in Kansas is ultimately dependent on the legislature, in Missouri the decision may come down to the voters. Medicaid expansion advocates have a long road ahead of them, and it will remain to be seen if they will collect the 170,000 signatures required by May. While advocates are optimistic, Missouri voters may get the final say on Medicaid expansion.

The Following is Part One in a two-part series on Medicaid Expansion

Last year, Democrat Laura Kelly was elected Governor of Kansas promising, among other things, to expand the state’s Medicaid program under the provisions of the Affordable Care Act. However, while Medicaid Expansion passed the State House of Representative in March, the legislation has been stymied in the State Senate, and Kansas remains one of the 14 states that have not expanded Medicaid. The battle over Medicaid Expansion is going to continue in the legislature’s next session.

Kansas is regarded by some advocates as doing the bare minimum. Medicaid is not offered to childless adults and is only available to parents making up to 38 percent of the federal poverty line, and those with disabilities making up to 74 percent of the federal poverty line, with more benefits available for children. Those who make between 100 and 400 percent of the federal poverty line are eligible for subsidized private health insurance plans from the Federal government. The amount varies depending on income, with more subsidies available to those closer to the poverty line. Currently, the Federal government pays up to 60 percent of the cost, with the rest coming out of the state budget. This leaves many Kansans in a situation where they make too much money to qualify for Medicaid under the state’s rules but too little to qualify for subsidies from the Federal government, what is commonly referred to as the Medicaid Gap. 

Medicaid Expansion would extend coverage to those in the Medicaid Gap, to people making up to 138 percent of the federal poverty line – roughly $16,753 per year for a single adult – with 90 percent of the costs being covered by the Federal Government. In Kansas, it is estimated that approximately 150,000 people would be eligible for coverage under Medicaid Expansion.

Medicaid Expansion legislation was passed by a coalition of Democrats and moderate Republicans in the Spring but was blocked by the Senate. State Representative Susan Ruiz (D-Lenexa) lays the blame for this squarely on Senate Majority Leader Jim Denning (R-Olathe) and Senate President Susan Wagle (R-Wichita), who refused to add the legislation to the agenda in the last session. 

“It’s in the hands of two people and it’s disgusting to me that they don’t have the moral compass to see how what they are doing not allowing Medicaid [Expansion] to happen,” Ruiz said. 

Some Senators attempted to overrule the Senate leadership and add the Medicaid Expansion to the agenda in the final week of the last session but fell just one vote short.

Denning has stated he intends to bring his own version of Medicaid Expansion to the Floor when the next session begins in January. He has formed a committee to draft the legislation which began meeting this last week. 

This Senate version has not been finalized yet but includes a provision to increase taxes on cigarettes by a dollar a pack, and a 5 cent per milliliter tax on vaping products, which would bring in an estimated $50 million in revenue. It would also add a $31 million dollar surcharge on hospitals and $63 million in fees assessed for managed care organizations serving Medicaid clients. Denning has argued that these taxes and fees are necessary to ensure Medicaid Expansion is revenue neutral. 

Senate President Susan Wagle previously floated the idea of adding work requirements for able-bodied recipients. However, such provisions were not included in Denning’s plan, much to the dismay of many conservative state legislators. The federal government has so far rejected all Expansion plans that included work requirements. 

When reached for comment, State Representative Rui Xu (D-Westwood) says that he expects Denning’s version of Medicaid Expansion to pass the Senate in the next session, meaning the legislation will come down to the conference committee, which leans conservative. He suspects this will result in the final version looking more like Denning’s yet-to-be-released plan. This could kick off a new fight in the state legislature next year if the House doesn’t approve the plan to come out of the conference committee. 

“It all comes down to who plays the game,” according to Xu.

He noted that it depends how willing moderate Republicans in the House will be to pass a version that doesn’t include as expansive coverage. Ruiz said she thinks “The majority of us,” referring to legislators who support Medicaid Expansion, “are ready for a fight and ready to mobilize if we need to.” She went on to say that the efforts of community organizations, activists and constituents are going to be crucial in making sure the best possible version of Medicaid Expansion is enacted. Xu and Ruiz both said that Medicaid Expansion is going to be a top priority in the next session, not only for them but for everyone involved.

This view was also expressed by Governor Kelly in a recent statement. 

“I have been clear that Medicaid Expansion will be my No. 1 priority in 2020,” Kelly said. 

The Governor further expressed her support for the version passed by the House in the last session.

“Simply expanding the Medicaid-eligible population to include adults who make up to $16,753 per year is the best path forward,” Kelly said.

 She encouraged state legislators to look at the experiences of other states that have expanded Medicaid.

“States with the best results and the most financial gain have the simplest plans,” Kelly said.

It is certain that the battle over Medicaid Expansion will be the defining issue of the next session for the Kansas legislature, but the outcome remains uncertain.