As lawmakers in a nearby hearing room debated last month whether to support her legislation to expand Medicaid, Gov. Laura Kelly of Kansas challenged the state's Republican House speaker to hold a vote.
“If he thinks he can kill him, bring him,” Ms. Kelly, a soft-spoken moderate Democrat, said in an interview in her vast office at the state Capitol in Topeka.
The next morning, in his office outside the House, Speaker Dan Hawkins showed no sign of relenting. He described the expansion of Medicaid as “almost like the biggest Ponzi scheme ever devised.” The same day, a House committee voted against passing Ms. Kelly's bill, derailing the proposal, at least for now.
The standoff between Ms. Kelly and Mr. Hawkins represented a clash in a fierce political battle playing out in several state capitals over the future of Medicaid, the health insurance program for the poor. In Kansas and a handful of Republican-controlled Southern states, supporters of expanding the program under the Affordable Care Act have renewed their efforts to overcome long-standing Republican opposition, generating a sense of progress.
Yet neither Kelly nor supporters of Medicaid expansion elsewhere managed to advance the legislation 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 deserve it.
“The fundamental moral question is where the safety net should be placed,” 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 frail, the elderly, the disabled and all low-income mothers and children.”
State-level clashes over Medicaid, which is funded jointly 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 is playing out with the 2024 presidential campaign as a backdrop.
In his reelection campaign, President Biden has highlighted his administration's work to safeguard the Affordable Care Act. Former President Donald J. Trump, the likely Republican nominee, has threatened the health care law in recent months, without detailing his plans on the matter. Health policy experts have said a second Trump administration could push for bulk granting of Medicaid, or allow states to limit the amount of money they spend on the program.
Kansas is one of only 10 states that did not expand Medicaid under the Affordable Care Act, which allowed adults with incomes up to 138% of the federal poverty level, or about $43,000 a year for a family of four people, to qualify for the program. All of Kansas' neighbors have adopted expansion, three of them — Missouri, Nebraska and Oklahoma — through ballot initiatives in recent years.
Those currently eligible for KanCare, as Kansas' Medicaid program is known, include children, parents, pregnant women and disabled people. The income limit for many adults to qualify is 38% 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 qualify for a heavily subsidized plan through the federal Affordable Care Act marketplace.
Ms. Kelly and other supporters of Medicaid expansion in Kansas have been making their case for years. In 2017, the Legislature passed a bill to expand the program, but it was vetoed by then-Republican governor, Sam Brownback. Ms. Kelly, then a state senator, campaigned on Medicaid expansion in her bid for governor the following year and in her 2022 re-election bid.
In her latest attempt to persuade lawmakers to go along with the expansion, Ms. Kelly has changed her approach. In December she introduced an expansion bill that includes a work requirement, offering Republicans a concession that she said could put them ahead.
“I tried everything else and it didn't work,” he said. “I wanted to take it off the table as an apology.”
At the state Capitol last month, House and Senate lawmakers held two hearings on Medicaid expansion — the first on the topic in four years, giving supporters of the legislation a sense of progress. Both audience halls were so crowded that visitors were forced to listen from the corridors or queue in the packed rooms.
There have also been signs of movement in Republican-controlled states in the South. In recent months, Republican leaders in Alabama, Georgia and Mississippi have expressed a new openness to expanding Medicaid. Lawmakers in the Mississippi House and Senate have approved several Medicaid expansion plans in recent weeks, despite intense pressure from 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 have also been failures. On the same day that lawmakers in Topeka blocked passage of Ms. Kelly's bill, a similar measure in Georgia passed in a Senate committee. Masterson, president of the Kansas Senate, argued that resistance in his state and elsewhere shows that momentum is heading in the opposite direction.
Masterson and other opponents of Medicaid expansion have argued that its long-term costs to state budgets are too severe. Supporters said the economic rationale is obvious, as the federal government covers 90% of the costs. A 2021 pandemic relief package further sweetened the deal for states that have yet to expand.
Ms. Kelly said the expansion would benefit the Kansas economy and create thousands of healthcare jobs. Officials at the state's community hospitals and clinics see the expansion as a potential lifeline for financially struggling rural providers.
Benjamin Anderson, CEO of Hutchinson Regional Healthcare System, a rural community hospital outside Wichita, told lawmakers at hearings last month that, as a lifelong Republican, he opposes the Affordable Care Act. But the challenges of the state health system in meeting the costs of treating the uninsured had convinced him to support the expansion of Medicaid. He noted that his hospital had to eliminate 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 Hawkins, who previously owned a health insurance agency, rejected the idea that Ms. Kelly's bill, with its work requirements, could influence voters. Regardless of the legislation, she said, the expansion would bloat the state budget and require taxpayers to pay for the medical needs of healthy adults who may be working and for employer or marketplace plans.
“Should we all provide them with something that they don't even care enough about to go to work and get it?” asked Mr. Hawkins. “What happened to our idea in this society that we should be self-sufficient, especially if we are able-bodied?”
The Kansas Health Institute, a nonpartisan research group, estimated that about 70% of those who would benefit from expanded Medicaid 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 coverage gap in Kansas. He said he has been unable to see a therapist for depression and other mental health needs, and that he has been unable to pay a medical bill of about $2,000 that he received for a heart monitor last year.
“It's definitely not people who are lazy,” he said. “It's people trying to improve their lives. I'm trying to pull up the bootstraps 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 was struggling to cope while caring for the complex medical needs of her daughter and her mother. daily activities such as dropping out of school.
Her doctor is careful not to order lab tests because of the potential unaffordable costs, Ms. Dodge said.
“It's a huge source of anxiety,” she said of not having health insurance. “There is the fear that I refuse to allow it to run my life. But it's there. And I can't help but recognize it.”
Hawkins acknowledged that the politics of the Affordable Care Act have changed as Republican opposition to the law has waned, making it a less potent issue to campaign against. “I just don't think he has the strength he once had,” she said.
Ms. Kelly said that if expansion supporters fail in the current legislative session, they would put the issue to the test during this year's election campaign. “This will be election issue No. 1,” she said.
Kelly predicted that expansion opponents were fighting a losing battle.
“They painted themselves into a corner,” he said. “And I think they have a hard time finding a way to save face.”