Kansas can't expand Medicaid unless top Republicans support it. Here's why they don't

For Medicaid expansion to pass in Kansas, it would need the backing of top lawmakers like House Speaker Dan Hawkins. So what's the possibility he'll support it?

"Zero," the Wichita Republican said in an interview in the House leadership offices in the Statehouse, within spitting distance of the House floor.

"There's no version," he said, "that I would support."

Low-income children, pregnant women, older Kansans and people with disabilities already qualify for state health care, as well as a small number of extremely low-income parents. A family of four must currently make less than $11,856 per year for the parents to qualify.

Expanding Medicaid would open eligibility to Kansans under 138% of the federal poverty level — including singles earning up to $20,783 annually and a family of four earning up to $43,056. The Kansas Health Institute estimates it would result in 152,000 low-income residents gaining health coverage.

Despite polls repeatedly finding a significant majority of Kansans support expanding Medicaid, the state is one of only 10 that hasn't done so. In recent years, that's thanks to stalwart opposition within its Republican-controlled Legislature.

Hawkins is a big reason for that. As one of the most influential voices in setting the Legislature's agenda, he's also one of Medicaid expansion's most staunch opponents. It's too expensive, he said — and he doesn't like that it would benefit working-age adults who, in his mind, should have to work to get benefits.

"With Medicaid expansion, there is no reason to work," he said. "They've got their health care now."

Nearly 60% of those who'd be covered under this year's expansion proposal actually do work at least 20 hours per week, according to a Kansas Health Institute analysis.

Often, their employers don't offer health insurance and they can't afford to buy it themselves on the Affordable Care Act Marketplace. Tens of thousands fall into what's called the coverage gap, which means they make too much money to qualify for Medicaid but not enough to qualify for subsidies that would make other insurance plans affordable.

In that gap are people like Tammy Shockley, a part-time warehouse worker in Shawnee Mission who is her granddaughter's legal guardian. Marissa Alcantar, an advocate with the pro-expansion organization Alliance for a Healthy Kansas, said Shockley is in a situation that's repeated across Kansas.

"She makes too much money to qualify for the Kansas Medicaid program," Alcantar said. "She isn't offered insurance through her job because she's a part-time employee."

Because Shockley is uninsured, Alcantar said, she hasn't been able to get the knee replacement that she needs.

"She's trying to stay working part-time and also care for her granddaughter," she added, "and not being able to get her knee surgery is something that prevents her from being able to work more hours."

This year, Democratic Gov. Laura Kelly is campaigning hard for her sixth Medicaid expansion proposal as governor. She calls it a "middle-of-the-road" plan that includes a work requirement. It's an effort to address critics' concerns — and perhaps lead voters concerned about the issue to break the state Legislature's GOP supermajority in this year's election.

A broad coalition of interest groups have joined the cause, from law enforcement groups to faith leaders. Supporters argue the proposal would be revenue-neutral due to federal offsets and would boost the Kansas economy.

Hawkins thinks Kelly's work requirement is too weak and might be thrown out by federal officials. He points out that more than a quarter of people who'd be covered under expansion already have other forms of insurance.

He said Kansas should instead increase the amount of money health care providers get for treating Medicaid patients — and tackle a massive waitlist that leaves Kansans with disabilities waiting years for critical services.

"(The governor) truly believes that the government should take care of everybody," he said. "I don't. I believe that we all have an individual responsibility."

Hawkins acknowledged the truth in one scenario touted by Kelly in an interview with the Kansas Reflector. A single mom of two kids currently has to earn less than $9,812 per year to qualify for Medicaid coverage herself — but she'll fall into the coverage gap unless she makes $35,631 per year, something that might be difficult while juggling childcare duties.

"That is true," Hawkins said. "But how many people are there? … We're going to spend billions in Medicaid expansion for just a few?"

His communications director, Carrie Rahfaldt, said that moms in a similar situation might qualify for a subsidy that could help them put in more hours at work.

A Republican base issue

The expansion debate gets down to fundamental disagreements over the role of government.

"There is always a strong strain of thinking in American politics that people shouldn't get government benefits who are undeserving," said Wichita State University political science professor Neal Allen, "and you become deserving of government benefits by working."

Among some conservatives, it also gets tied into hot-button issues like immigration and gender-affirming health care — something evident at a recent Wichita Pachyderm Club luncheon focused on concerns about expansion.

Toward the end, Ed Myers, a retired investor from Newton clad in a "Make America Great Again" hat and a Rush Limbaugh shirt, stood up.

"I understand that California is also going to pay for transgender surgeries for illegals under Medicaid," he said. "Are those states that have Medicaid — are they going to be forced, eventually, by the federal government, to pay for the illegals' health care?"

Michael Austin, a legislative director with the conservative political action group Americans for Prosperity who presented at the meeting, said he wouldn't be surprised.

"It's a Trojan horse," he said. "I can't give you all the different consequences or strings that are going to come from accepting any federal program."

California recently began allowing eligible undocumented immigrants to get Medicaid coverage, and the state's program does cover gender-affirming care when deemed medically necessary. But Kansas already excludes most kinds of gender-affirming care from Medicaid coverage.

Conflict within the GOP

Despite the opposition from high-profile Republicans, the party is not a monolith on the issue of Medicaid expansion. A little over half of Kansas Republicans who responded to two recent surveys said they support expanding Medicaid.

And Republican lawmakers have advanced the proposal before. It last passed the House in 2019 before dying in the Senate, and it passed both chambers in 2017 before it was vetoed by then-Gov. Sam Brownback.

The Kansas Republican caucus and its leaders have become more conservative in the years since. Still, a handful of Republican lawmakers remain dedicated to the cause. Several told the Kansas News Service that they're frustrated by what they see as stonewalling by opponents. That frustrated group includes Rep. Susan Concannon, of Beloit.

"(Medicaid expansion) is pro-business, which is a Republican priority," Concannon said. "It's pro-life."

Concannon used to work alongside Hawkins as vice chair of the House health committee when he was chair. She said that while the two have been able to work together on a lot of issues, Medicaid expansion is not one of them.

"If leadership holds a position on something," she said, "it's hard to be heard."

Sen. Carolyn McGinn, another Republican, thinks GOP leaders have, at times, gone to extreme lengths to block expansion.

"We had leadership, at one time, that wouldn't run any kind of bill that could allow a Medicaid amendment to reach the floor," said the vocal expansion proponent who's represented the Wichita area for nearly two decades. She recently announced her intention to retire at the end of her term.

"(They) were stopping other health care legislation," she added, "just because (they) were worried that something with Medicaid would get amended into it."

Some younger lawmakers are taking a different tack. Rep. Jesse Borjon, a Topeka Republican first elected in 2020, recently penned a letter to Hawkins urging him to hold a hearing on expansion. He argued that it would help attract more workers to Kansas at a time when many industries are struggling to hire.

"One of the number-one issues that I hear from my constituents on is Medicaid expansion," he told the Kansas News Service. "They can't understand why the Legislature can't get it done."

In a recent development, leadership has agreed to hold committee hearings on Medicaid expansion in the coming weeks. Still, Hawkins said there's no chance it will become law.

"It will not pass this year," he said, "because there's not the votes for it."

He estimated slightly over 50 representatives support it, short of the 63 required to pass legislation.

Concannon disagrees with that logic. She thinks there are a lot of Republicans — conservatives, even — who might support expansion if they learned more about it. The proposal last got a formal House hearing in 2020, meaning lawmakers elected since haven't had an opportunity to hear debate.

"We can't even count votes until they know all the facts," she said, "and that requires hearing testimony."

A looming election

For Republicans, the stakes are high. Letting the issue reach the floor of either chamber for a vote would force lawmakers to go public with where they stand.

That could make Republicans in swing districts vulnerable to Democratic challengers next election if they oppose expansion, Allen said. That could threaten a handful of Republican-held seats in Northeast Kansas and, along with it, the party's supermajority in the Kansas Statehouse.

What's more, he said, Republicans in most rural districts are unlikely to vote for expansion — despite some evidence that rural populations would disproportionately gain coverage under expansion.

"Winning or losing reelection for a rural Republican is really just about winning your primary," he said. "And if they do have (primary) vulnerability, it's likely for not being conservative enough."

Opponents like Hawkins dismiss polls that repeatedly find a majority of Kansans support expanding Medicaid. He said they're confusingly worded; that people don't know what they're supporting. He points to a poll he commissioned in 2019 that found over three-quarters of respondents — all likely Republican primary voters — said they oppose expansion to cover able-bodied working age Kansans.

"When you start educating people what Medicaid expansion is," Hawkins said, "the polls change."

Voter will

Even as the governor rallies pro-expansion Kansans to put pressure on their representatives this fall, it's unclear how much sway voters will exercise.

Kansans have a track record of electing lawmakers out-of-step with their beliefs on the Medicaid issue. The same survey that found around 70% of Kansans support expanding Medicaid found that less than half say the issue is highly important when choosing who represents them in the Kansas Legislature.

And because Kansans elect their representatives by legislative districts, statewide support for expansion doesn't necessarily translate into support in a majority of legislative districts.

Allen said the structure of Kansas lawmaking gives even more power to leaders like Hawkins.

"We have a short legislative session that gives more influence and power to those in the leadership, who control the agenda," he said.

"Right now, the Republican party, at least on the state level, doesn't want to expand Medicaid," he added. "And in Kansas, what Republicans want is what matters."

Many reliably red states have expanded Medicaid, including neighboring Missouri, Oklahoma and Nebraska. But it usually happens through citizen-led ballot initiatives, which don't exist in Kansas. For now, that leaves the Statehouse, and the powerful Republicans who control it, as the only path forward for expansion.

Proponents like Concannon will keep advocating for the cause, but she's not holding her breath.

"I never lose hope," she said. "I don't necessarily have any confidence that it will be done this year. But we're not ready to give up."