When the Affordable Care Act was enacted in 2010, Medicaid expansion was a cornerstone of lawmakers’ efforts to expand realistic access to healthcare to as many people as possible. The idea was that everyone with household incomes up to 138% of poverty would be able to enroll in Medicaid.

Since 2010, the number of states that have accepted ACA’s Medicaid expansion has steadily grown – from just a handful by 2012, when the program went into effect, to 35 states and DC as of early 2020.

Midwest, heavily Republican and Southern states were the big hold-outs and still are. Nebraska, Kansas, Oklahoma, Missouri were holds, with Nebraska voters finally approving Medicaid expansion in 2018 via a ballot initiative.

Once again, this year, Kansas and Missouri will take on this issue, but this time it appears their efforts will take them down different paths. SEE SLIDESHOW BELOW FOR STORIES

UNDERSTANDING THE NEED FOR MEDICAID EXPANSION

When it was approved, the Affordable Care Act only covered individuals and families with an income equal to or above the Federal poverty line. The idea was that people below this level might have trouble paying the monthly premiums under the ACA. 

For those individuals the program proposed the expansion of Medicaid coverage by the states with the federal government offering to pay up to 90% of the cost.

In Kansas, Medicaid (known as KanCare) provides health coverage for approximately 377,000 poor, disabled and elderly residents. Non-disabled, childless adults are not eligible. To qualify for Medicaid, non-disabled parents must earn less than 33% of the federal poverty level, or about $6,700 for a single mother with two children.

So, individuals who earned more than 33% of the federal poverty level and less than 100% of the federal poverty level fell into what was call the Medicaid gap. They were too rich to qualify for Medicaid and too poor to qualify for ACA.

Originally, the drafters of ACA planned for the individuals in the coverage gap to be covered by the state’s expansion of Medicaid. However, the Kansas Legislature voted not to expand Medicare, despite the federal governments agreement to cover 90% of the cost.

ACA proposed the expansion of Medicaid to include those whose income was up to 138% of poverty as a way to lessen the burden of insurance premiums on those with lower income. During previous discussions on the expansion of Medicaid in Kansas, proposals included expanding Medicaid only to those whose income was 100% of poverty versus 138% and a work requirement for non-disabled Kansans to be covered under the expansion plan.

HOW KANSAS SEEMS TO HAVE REACHED MEDICAID EXPANSION COMPROMISE 

By the Mainstream Coalition

We may have mentioned once or twice that Medicaid expansion will be a big topic in this year’s Kansas Legislature – as it was last year, and the year it actually passed, only to be vetoed by Gov. Brownback, with the vote to overturn the veto failing by one vote in the Kansas Senate. Well, we have reason to believe this might be the year it gets done.

Earlier this month, Gov. Laura Kelly (D), and Sen. Jim Denning (R) announced they had reached a compromise, and would introduce a bill to be considered this session. That bill has now been filed, SB252, “Expanding medical assistance eligibility and implementing a health insurance plan reinsurance program.”

The bill is complex, because health insurance is complex. We’ve consulted with our partners in health care advocacy, and here is what you need to know.

The Compromise

Gov. Kelly held meetings this fall with her council on health care expansion, to study and come up with policy solutions. Sen. Denning held hearings and discussions, too, with a Legislative committee. As the Legislative Session approached, they worked together to craft something they could bring forward.

The result has some compromises for both sides.

If passed as written, SB252 would implement Medicaid expansion to start next year, January 1, 2021. It would expand the people eligible for coverage to earning 138% of poverty, the Federal standard in the Affordable Care Act. That would allow the 150,000 working Kansans who right now fall in the coverage gap to gain access to affordable health care. Don’t understand the coverage gap? Read the story this page.

A premium, meaning a fee to be enrolled, is a barrier to access. But the premium included in the bill contains a sliding scale, and assistance for those unable to pay. Lockouts—throwing enrollees off the program and preventing re-enrollment for a period of time if they cannot pay—are not included in the bill, and that is a win. Nobody would be thrown off health care, and kept off, if they are unable to pay. A work requirement dictating that enrollees be working at a job is another common barrier to access, and is not included in this bill. Instead, the work referral program helps people who need it.

On the topic of work requirements, truth is, of the 150,000 people who would become eligible, most are already working, others are caregivers at home, and still others are unable to work due to illness or disability. Only about 6% of them are able to work and are not employed. The bill will encourage those Kansans to find work, and offer assistance in doing so.

The myth that there are an enormous number of lazy, lay about adults who are living off the government is just that, a myth. Work requirements are extremely expensive to administer for state governments, especially given the small number of people affected, and many states are reconsidering or delaying their work requirement provisions.

MISSOURI COULD DECIDE TWO MEDICAID ISSUES ON NOV. BALLOT 

Unlike their neighbors to the West, it doesn’t look as though Missouri will be able to find a workable way to expand Medicaid during their 2020 legislative session, so the issue may end up in the hands of the electorate during the November election.

During his State of the State speech earlier this month, Missouri Gov. Mike Parson confirmed his commitment to fighting expanding the number of people eligible for Medicaid. Not only will will he oppose it in the legislature, Parson says he’ll opposes a ballot initiative the expand Medicaid that is gaining momentum across the state

Advocates are collecting signatures to put the issue on November’s ballot. The proposed constitutional amendment would allow adults earning up to 138% of the federal poverty level to access Medicaid starting in July 2021.

On Thursday, he told The Associated Press that expanding Medicaid eligibility would mean taking money away from education, workforce development, and roads and bridges in order to pay for health care for more people.

Absent action by Missouri lawmakers, advocates for greater access to government health care now are trying to put the issue to a public vote.

A campaign raising money for the effort brought in more than $3 million as of the end of 2019 and spent $1.9 million in recent months. Top donors include the Missouri Hospital Association, which gave $500,000, and Washington University, which donated $250,000. Most of the spending went to pay workers to collect enough signatures to get the measure on the ballot.

Healthcare for Missouri’s campaign manager, A.J. Bockelman, said Thursday that the campaign had gathered roughly 90,000 petition signatures so far, which is more than half of roughly 172,000 needed to qualify the measure for the November ballot.

Bockelman declined to respond to Parson’s suggestion that the expansion initiative amounted to a tax increase but instead pointed to a Washington University study suggesting that Medicaid expansion could produce savings for the state.

Work Requirement

In a related issue, Republican lawmakers are pushing to make Missouri’s Medicaid recipients find jobs if they want to keep their health coverage. Sen. David Sater, R-Cassville, has proposed putting a constitutional amendment on the November ballot to add work requirements for some able-bodied Medicaid recipients.

it’s not clear how this latest effort would be squared with the petition to extend benefits to additional low-income people. The petition being circulated specifically prohibits work eligibility standards.

Both proposals could land on the ballot in November.

“We are concerned about it, and it’s really unclear how that would resolve itself,” said Shawn D’Abreu, policy director for Missouri Health Care for All.

The last time there were conflicting ballot measures — during the push to legalize medical marijuana — the secretary of state’s office said whichever constitutional amendment received the most votes would overrule the other.