When Vice President Mike Pence complained recently that the Affordable Care Act’s Medicaid expansion had put “able-bodied adults” ahead of people with disabilities, Ohio Gov. John Kasich, a fellow Republican, quickly jumped in to dispute that and defend the expansion.
It was deja vu for people who have followed the long Medicaid expansion debate in Kansas.
For years a small but growing group of Kansas Republicans have pushed to accept the ACA’s federal money to expand Medicaid eligibility to everyone who makes up to 138 percent of the federal poverty line.
For years more conservative Kansas Republicans have successfully pushed back, arguing the state’s program should remain largely restricted to children, pregnant women, the elderly and people with disabilities.
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The intra-party rift has both practical and ideological fault lines and, with Republicans now in control of Congress and the White House, it’s one of the issues thwarting the party’s efforts to repeal the ACA, commonly called Obamacare.
About half of Republican-led states have expanded Medicaid and about half, including Kansas and Missouri, have not. Congressional Republicans have struggled to find a plan to roll back the expansion without causing too much angst for expansion-state senators like Nevada’s Dean Heller, Ohio’s Rob Portman and Alaska’s Lisa Murkowski.
“Medicaid expansion, I think, continues to be that pivotal issue in the whole thing,” said Kansas Rep. Dan Hawkins, a Republican from Wichita who has been at the center of state-level expansion fights as chairman of the Kansas House Health and Human Services Committee.
Those fights culminated this year in an expansion bill passing, only to be vetoed by Kansas Gov. Sam Brownback. Republicans in the Kansas Legislature were almost evenly split on a vote to override the veto, which narrowly failed.
Hawkins adheres to the same position as Pence and Brownback: Medicaid’s not for everyone.
“It was meant to take care of those who can’t take care of themselves,” Hawkins said. “Never, ever was it meant to insure able-bodied adults and now all of a sudden that’s what we’re trying to do.”
Kansas Sen. Barbara Bollier, a Republican from Mission Hills who said she was for expansion “before it was cool,” falls more in the Kasich camp.
“There are multiple reasons why I have felt so strongly about this and it starts first with justice for all and my belief system that everyone should have access and basically be cared for,” said Bollier, a retired physician.
Additionally, Bollier said somebody has to pay to care for the uninsured, and right now it’s hospitals that are forced by law to see people in their emergency rooms, often without compensation.
The Kansas Hospital Association has been keeping a running tally of how much federal expansion money the state has foregone that could be shoring up the budgets of struggling facilities, especially in rural areas. The tally passed $2 billion this week. Missouri Hospital Association vice president David Dillon said the figure is close to $6 billion in his state.
A national study published last year found that about one-third of rural Kansas hospitals are at risk of closing.
Across the border in the nearest expansion state, Colorado, the CEO of Holyoke’s Melissa Memorial Hospital, Trampas Hutches, said expansion has been a game-changer.
“Prior to expansion of Medicaid we were losing about 3 to 4 percent of our operations margins every year,” Hutches said. “For us, that’s the equivalent of about $600,000 or $700,000 a year in loss.”
After expansion, Hutches said his percentage of uninsured patients went from 16 percent to 5 percent, his percentage of Medicaid patients went from 7 percent to 15 percent, and his 3-4 percent financial losses turned into 3-4 percent annual gains.
“With those good margins, you have the ability to offer services you can’t usually in a small town,” Hutches said, including dental care, optometry and a primary care clinic.
Hawkins said he knows some Kansas hospitals are struggling, but Medicaid expansion is not a long-term answer because the federal government can’t afford it.
Julius Hobson, a health policy expert at the Polsinelli law firm in Washington, D.C., said that barring changes to current law, Hawkins is right.
“Medicaid and Medicare are going to have to be dealt with at some point because the growth in the two programs is going to exceed the government’s ability to pay in a decade or two,” Hobson said.
Still, Hobson said a full rollback of Medicaid expansion would be politically very difficult for Republicans in expansion states, and it’s unlikely to happen if history is any guide.
“Whenever Congress has enacted an entitlement, they have never taken it away,” Hobson said.