Supporters of Medicaid expansion celebrated this week after the Kansas House voted to expand the program to some 150,000 residents.
One lawmaker called it “monumental” after nearly a decade spent trying to get the conservative state to open up the state-run health program to more Kansans.
Even Democratic presidential candidate Bernie Sanders posted a congratulatory tweet.
But expansion hopes will collide with political reality in the state Senate, where the proposal heads next. Republican leaders who oppose the plan—a top priority for Democratic Gov. Laura Kelly—wield enormous power over its fate. Expansion supporters expect they will use it to prevent the bill from ever reaching a floor vote.
In the coming weeks, tens of thousands of Kansans who would qualify for expanded Medicaid—those currently ineligible because they make too much, but too little to qualify for the Affordable Care Act—will watch what path senators take.
What they can expect is a messy, unpredictable journey.
Lawmakers could strike a grand bargain: Medicaid expansion in exchange for something its opponents want, perhaps a tax cut. They could deploy unusual procedural tactics to force votes. It’s also possible legislators will delay action until next year in favor of more study.
Or they could do nothing at all.
“None of us have any idea how this is going to move forward at this point, but this is one of the governor’s and the majority of the Legislature’s … both of their priorities,” said Sen. Barbara Bollier, a Mission Hills Democrat who has championed expansion.
A bargain may offer expansion supporters their best shot at sending a plan to Kelly, who would almost certainly sign it into law. It could play a powerful role in negotiations as lawmakers try to strike deals and get out of Topeka.
“I think at the end of the day it’s going to be in a mix of a number of different issues before we can bring the gavel down on the 2019 session,” Senate Minority Leader Anthony Hensley, a Topeka Democrat, said of expansion.
With Democrats now controlling the governor’s office for the first time in eight years, both parties may need to negotiate to advance any of their major priorities – whether it’s expansion for Kelly or tax changes that Republicans want but Kelly opposes.
Senate Majority Leader Jim Denning, an Overland Park Republican, said he has asked for a meeting with Kelly to discuss Medicaid expansion and other issues, like the state budget. A spokeswoman for the governor confirmed the two plan to meet.
Denning, who has opposed expansion in the past, expressed concerns about how it would affect the budget. He also warned that once the state applies for permission to expand, it’s in the hands of the federal government.
“You don’t come back next year and fix it,” he said. “She’s going to have to tell me where she’s heading.
The House’s passage of expansion occurred only after lawmakers took the extraordinary step of bypassing the chamber’s rules chairman—basically a parliamentary referee—to allow a Medicaid amendment to be offered on a separate health bill in a move known as a “gut and go.” The House then approved the bill in a 69-54 vote.
Similar action is much less likely in the Senate.
The rules require a two-thirds supermajority of 27 votes to force debate on a bill. Short of that, Republican leaders exert total control over what bills are brought to the floor.
Twenty-five senators supported expansion in 2017, two shy of what’s needed to force debate. That has likely dropped to 24 because Sen. Vicki Schmidt, a moderate Republican, was replaced by the more conservative Sen. Eric Rucker, who used to work in Secretary of State Kris Kobach’s office.
“I think the Senate Republican leadership should take a lesson from what happened over in the House, that they ought to let people have an opportunity to debate and vote on the bill,” Hensley said.
Under the normal legislative process, bills are sent to a committee and a hearing is held. The committee, after working on the proposal, then votes on whether to send it to the full House or Senate.
Committees in the House and Senate have not held hearings on Kelly’s plan, though a House panel convened roundtable discussions on the general topic of Medicaid expansion.
A leading proponent, the Alliance for a Healthy Kansas, plans to focus on educating senators about expansion’s benefits, said April Holman, the group’s director. She predicted the issue won’t follow the normal path to passage in the Senate.
“I think it’s probably going to be similar to the House path in that it’s not going to take the traditional route of committee hearings, committee debate, floor debate – some of those things your normal bill would do,” Holman said.
‘A lot of game playing’
While the specifics have shifted from year to year, the broad outlines of Medicaid expansion remain the same: the federal government pays 90 percent of the cost with states chipping in the last ten percent.
In order to qualify, Kansas would expand eligibility to those making up to 133 percent of the federal poverty level, or $16,611.70 for an individual.
Estimates place the annual cost to Kansas at $34 million and $47 million. Kelly and other supporters say it’s a modest amount to extend coverage to as many as 150,000 people.
Kelly has expressed confidence the Legislature will expand Medicaid this year, while acknowledging the power Republican leaders to thwart action.
“There’s been a lot of game playing with that,” Kelly said in an interview last week, conducted before the House vote. “The leadership of both the House and Senate have done what they’re perfectly able to do, which is to block any debate, either in committee or on the floor on Medicaid expansion.”
Republican opponents have questioned whether the federal government will hold up its end of the deal into the future. Democratic and Republican supporters say the program will expand health coverage and also aid financially struggling rural hospitals.
Kansas House Majority Leader Dan Hawkins, a Wichita Republican, said Sanders’ tweet proved the Medicaid expansion plan passed by the House is “a radically liberal agenda designed to push us closer to a single-payer system.”
More study wanted
Senate President Susan Wagle, a Wichita Republican considering a run for U.S. Senate, has said hearings on Medicaid expansion is not a top priority. On Friday, Wagle spokeswoman Shannon Golden said Senate leaders would discuss the issue next week.
“Senate President Wagle’s position on Medicaid expansion is very clear,” Golden said.
Sen. Gene Suellentrop, a Wichita Republican, chairs the Senate Public Health and Welfare Committee—the panel that would likely hold hearings on the House bill. He wants lawmakers to study expansion further.
He said he is open to talking with all sides on and looking for a compromise going into the 2020 session.
“It would be my hope that we do an interim (committee) during the summer and take a look at it carefully and come out with an approach that we feel like makes sense,” Suellentrop said.
Bollier rejects that idea. Lawmakers have years of data to look at from states that have already expanded, she said. And organizations like the Kansas Health Institute continue to produce reports on the anticipated effects of expansion.
“There is no need for an interim study,” Bollier said. “We have had years of information.”