House and Senate pass expansion, Governor vetoes it
On February 23, 2017, H.B.2044 passed the Kansas House of Representatives, 81-44. A month later, the bill passed the Senate, 25-13. But Governor Sam Brownback has remained steadfast in his opposition to Medicaid expansion, and on March 30, he vetoed it. Although the Medicaid expansion legislation passed by a wide margin in both chambers, it was a few votes shy of a veto-proof majority.
On April 3, the House voted to uphold Brownback’s veto. The final margin was 81-44, three votes shy of the 84 votes that would have been necessary to override the Governor’s veto. Two representatives who had voted for expansion ended up voting to uphold the veto, while two others who had opposed the expansion vote shifted sides and voted to override the veto. In the end, the numbers ended up the same as they had been the prior week, and the governor’s veto remains in effect.
Brownback listed several reasons for vetoing H.B.2044:
- He wants Medicaid reform to eliminate the current waiting lists for disabled Kansans (a population that was already eligible for Medicaid pre-ACA)
- He wants Medicaid reform to be budget neutral for the state (expanded Medicaid is funded almost entirely by the federal government, but states currently pay 5 percent of the cost, and that will grow to 10 percent by 2020).
- He wants a work requirement for able-bodied adults (as opposed to the work referral program in H.B.2044)
- He wants Medicaid reform to cut funding for Planned Parenthood, and H.B.2044 does not do that.
- He believes it’s “unwise” to expand Medicaid given the uncertainty of the ACA on the federal level (to be clear, GOP efforts to repeal provisions of the ACA and overhaul Medicaid expansion stalled earlier in March, when the AHCA was pulled before it reached a vote; for the time being, the ACA remains the law of the land).
In 2014, Brownback signed legislation (H.B.2552) that requires legislative approval in order to expand Medicaid (as opposed to allowing it via executive action, which is the path that governors in some states have used to expand Medicaid without having to obtain approval from lawmakers). H.B.2552 was popular with Brownback and 2014’s more-conservative legislature, particularly given the strong-than-anticipated gubernatorial campaign of then-House Minority Leader, Paul Davis — a Democrat who supported Medicaid expansion.
The American Cancer Society, which supports Medicaid expansion, reported that 82 percent of Kansas survey respondents wanted the state to accept federal funding to expand Medicaid. Hospital leaders in Kansas also pushed hard for Medicaid expansion, noting that without expansion, some rural hospitals would be forced to close. Although the measure passed by a wide margin in both chambers, it simply wasn’t enough to overcome the governor’s veto.
The result is that Medicaid expansion in Kansas is dead for now. But this isn’t necessarily the end of the issue, even for this year. A budget bill later in the year could resurrect the question of Medicaid expansion, so stay tuned.
AHCA would have ended Kansas expansion efforts
The American Health Care Act, introduced by in the U.S. House of Representatives on March 6, initially called for states to be able to continue to expand Medicaid (with the enhanced federal funding that applies to Medicaid expansion) until the end of 2019. But on March 20, an amendment was added to the legislation, including technical changes and policy changes. The policy changes (summarized here) included a provision that would have eliminated the ability for states to expand Medicaid with full ACA funding as of March 1, 2017. States would have been allowed to opt into Medicaid expansion after that point, but federal funding would have been at the normal rate that applies for the state, as opposed to the ACA’s 95 percent federal funding for Medicaid expansion that applies from 2017 through 2019, and the 90 percent federal funding that applies after 2020.
In Kansas, the normal federal matching rate is about 56 percent. So if the federal government had enacted the amended AHCA, Kansas would technically have be able to proceed with Medicaid expansion, but with much less in federal funding. The state would have had to make up the difference with state funds, which would likely have resulted in the nascent expansion plan dying before it gets off the ground.
However, on March 24, Republican leadership opted to pull the AHCA minutes before a vote, as they didn’t have enough support in the House to pass it. Kansas lawmakers quickly moved forward with votes to expand Medicaid at that point, although they did not have enough votes to override Brownback’s veto. By early April, however, it appeared that the AHCA was once again under consideration, this time with more concessions being made for the ultra-conservative House Freedom Caucus. It was unclear at that point what specifics regarding Medicaid expansion would be included in a possible new version of the bill.
The details of the state’s vetoed expansion plan
H.B.2044, as amended prior to its passage in the Kansas House, called for Medicaid expansion in Kansas as of January 1, 2018. There are 150,000 people in Kansas who were expected to be newly eligible for coverage if Medicaid eligibility were expanded to 138 percent of the federal poverty level, as called for in the Affordable Care Act (ACA). The bill included a provision to refer unemployed or underemployed (fewer than 20 hours per week) enrollees to a work training and job search program, although there was an exemption for stay-at-home parents of minor children, and for full-time students.
The March 20th Manager’s Amendment to the AHCA had called for an optional work requirement that states could implement for their Medicaid expansion populations; this differed from the Obama Administration’s approach, which steadfastly refused work requirement proposals from states seeking to expand Medicaid with 1115 waivers. Ultimately, the AHCA failed, although the Trump Administration HHS will likely be more lenient than the Obama Administration was in terms of things like work requirements in 1115 waiver proposals.
H.B.2044 was originally introduced in order to include community-based rehabilitation services as a covered benefit under Kansas Medicaid. But Democrats and moderate Republicans in the Kansas House of Representatives amended the bill to include Medicaid expansion, and passed it through the House Committee of the Whole by a wide margin (83-40; it needed 70 votes to pass), after more than 160 people — representing stakeholders all over Kansas — testified in support of Medicaid expansion, while just five testified in opposition.
The move to amend H.B.2044 and pass it through the Committee of the Whole came the day after the House Health and Human Services Committee had voted 9-8 to table a Medicaid expansion bill (H.B.2064) until at least April 3. That had effectively killed H.B.2064, since February 23 is the deadline for bills to move out of the chamber where they originated (however, the committee vote on H.B.2064 marked the first time a Kansas legislative committee voted on a Medicaid expansion bill; others have been introduced over the last few years, but have died in committee without a vote).
H.B.2044 passed the House by a wide margin (81-44), but the vote was three short of what would be needed to override a veto. The Senate’s 25-13 vote is two short of the number needed to override a veto.
The Kansas Hospital Association notes that by not expanding Medicaid for the last three years, the state has missed out on $1.7 billion in federal funding that would otherwise have flowed into the Kansas economy and helped struggling hospitals stay afloat.
Optimism about expansion began growing in 2016
In September 2016, Sandy Praeger, a Republican and former Kansas Insurance Commissioner, called on Governor Brownback and Kansas lawmakers to expand Medicaid, saying that there’s “no logical explanation” for the state’s continued rejection of federal funding for Medicaid expansion, and noting that the decision has been based on politics rather than cost analysis.
And the state’s primary election in August 2016 resulted in several moderate Republicans getting onto the ballot for November, energizing Medicaid expansion advocates. Supporters became more confident than ever that they could get a bill passed in 2017 to expand coverage, particularly given that several of the primary winners had been outspoken about their support for Medicaid expansion.
Several conservative Kansas lawmakers were indeed replaced with Democrats and moderate Republicans, but Donald Trump also won the presidential election in November 2016, and suddenly the future of the entire ACA — including Medicaid expansion — was up in the air (you can follow our blog for more information).
Advocates continued focus on expansion
Although the uninsured rate in Kansas is at an all-time low of 10.5 percent, advocates note that there are 50,000 uninsured Kansas residents who would be eligible for Medicaid if the state were to expand coverage, and a total of 150,000 who would be newly eligible for Medicaid under expansion.
Kansas has thus-far decided against expanding its Medicaid program, despite a December 2013 poll that found 72 percent of registered Kansans voters favored expansion. The Kaiser Family Foundation estimates that 56,000 Kansans are in the coverage gap, given the state’s rejection of Medicaid expansion. Individuals in the coverage gap earn too much to qualify for Medicaid, but not enough to qualify for premium tax credits that would help them purchase private health insurance through the marketplace.
In October 2015, Mercy Hospital in Independence, Kansas announced that it would close, becoming the first Kansas hospital to shut down in nine years. The hospital’s closure has been linked to the state’s rejection of Medicaid expansion. In states that don’t expand Medicaid, the uninsured rate remains higher and hospitals continue to struggle with higher levels of uncompensated (charity) care – particularly since federal funds to offset uncompensated care costs are being phased out now that states have the option to expand Medicaid.
Mercy Hospital’s announcement triggered renewed calls for Medicaid expansion in Kansas, but Governor Brownback’s administration has thus far remained steadfast in their refusal to expand Medicaid to all adults with household income up to 138 percent of the poverty level. In response to editorials calling for Medicaid expansion in the state, an email from Brownback’s deputy communications director Melika Willoughby described Medicaid expansion as “morally reprehensible” and an “Obamacare ruse [that] funnels money to big city hospitals.” The email also said that Medicaid expansion would create a new entitlement “for able-bodied adults without dependents, prioritizing those who choose not to work before intellectually, developmentally, and physically disabled, the frail and elderly, and those struggling with mental health issues.” [This is disingenuous, though, as 60 percent of adults in the coverage gap are in an employed household; the problem is that their jobs are low-paying and don’t provide health insurance.]
A Medicaid expansion bill, HB 2319, was introduced in the 2015 session and got a hearing before the House Health and Human Services Committee. The acting secretary for the Kansas Department of Health and Environment testified that expansion would cost the state $2.4 billion between 2016 and 2025, and the committee didn’t act on the bill.
The federal government will always pay at least 90 percent of the cost of Medicaid expansion, but states will be responsible for ten percent of the cost by 2020. However, Kansas hospitals are projected to lose $2.6 billion between 2013 and 2022 if the state continues to reject Medicaid expansion. The state is also missing out on $5.3 billion in federal funding over that same time period by not expanding Medicaid. And a new Kaiser Family Foundation study found that states that have rejected Medicaid expansion actually saw their share of Medicaid spending increase twice as much in fiscal year 2015 as state Medicaid spending in states that have expanded coverage.
Brownback’s position remained unchanged in 2016 and early 2017; he maintains that the state cannot afford to expand Medicaid, and that he would only consider expansion if it were budget neutral. Brownback has said that the state should not move forward with expansion of Medicaid while they have currently-eligible residents who are on waiting lists for Medicaid services (part of that problem can be attributed to issues with KanCare, discussed below).
The Alliance for a Healthy Kansas renewed their call for Medicaid expansion in 2016, and launched a state-wide campaign to educate voters about the lawmakers who were on the ballot in November, and how voters can influence the state’s course on Medicaid expansion.
Current Medicaid eligibility in Kansas
Medicaid programs and eligibility vary widely across the country. The federal government sets minimum eligibility levels for specific populations, but states can choose to set their eligibility levels higher than the federal minimums. All states are required to provide Medicaid to certain populations — like low-income children — to qualify for federal Medicaid funding. States that opt to cover additional populations are eligible for additional funding.
Unfortunately for low-income individuals in Kansas, the existing Medicaid program — which is called KanCare — is quite limited.
Kansas is one of 19 states that has not yet accepted federal funding to expand Medicaid to adults with income up to 138 percent of the federal poverty level. As a result, childless adults are not eligible for coverage regardless of how low their income is, and parents with dependent children can only qualify if they live in extreme poverty.
Individuals who meet the following income limits qualify for Medicaid in Kansas:
- Children up to age 1 are covered with family income up to 166 percent of the federal poverty level (FPL)
- Children ages 1 to 5 are covered with family income up to 149 percent of FPL
- Children ages 6 to 18 are covered with family income up to 133 percent of FPL
- Parents with dependent children are eligible with household income up to 33 percent of FPL. For a family of three, that’s $6,738/year in 2017.
- Children with family income too high to qualify for Medicaid are eligible for the Children’s Health Insurance Program (CHIP); the income limit is 242 percent of FPL
- Individuals who are elderly or disabled may also qualify for KanCare; see the eligibility guidelines
See the income limits use the online screening tool to see if you may qualify.
As of July 2013, enrollment in Kansas Medicaid/CHIP was 378,160. By November 2016, it stood at 416,379, which was a 10 percent increase since 2013 (although the total decreased slightly from July 2016 to November 2016).
From 2013 through at least 2015, Medicaid enrollment in Kansas among children age 1 to 5 had been declining, although state Medicaid officials haven’t pinpointed a specific reason and note that some of the children may be covered under CHIP instead (CHIP enrollment has grown slightly since 2013).
Kansas Action for Children, a state advocacy group, believes that the decline in Medicaid enrollment among young children is correlated with the fact that Kansas decoupled applications for Medicaid and TANF a few years ago. The plan was for the new Kansas Eligibility Enforcement System (KEES) to begin coordinating enrollment in various public programs in 2013, but it’s been delayed repeatedly and the system was not yet fully operational as of fall 2015.
How to enroll in KanCare
Kansas Medicaid has been experiencing an enrollment backlog since late 2015, due to a combination of a new computer system, all enrollments going through a single state agency, and an influx of new enrollees during the ACA’s enrollment period (Medicaid enrollment is year-round, but tends to peak during the individual market’s open enrollment period due to outreach and advertising; despite the fact that Kansas hasn’t expanded Medicaid, the “woodworker” effect means that people who were already eligible have been enrolling in larger numbers since 2014.
The state is working to get the backlog down to its historical levels before the 2017 individual market open enrollment period begins in November 2016.
For children and families:
- Apply online (or through Healthcare.gov).
- Complete an application. English and Spanish versions are available, or call 1-800-792-4884 to have an application mailed to you.
- You may return the application by fax: 1-800-498-1255.
- You may also submit the application in person or by mail. Use the office locator tool to find the address or phone number for a nearby Department for Children and Families (DCF) office.
- If you need help with the application process, contact DCF toll free at 1-888-369-4777.
For elderly or disabled individuals:
- Apply online.
- Complete an application. English and Spanish versions are available, or call 1-888-369-4777 to have an application mailed to you.
- Return the application by fax: 785-296-4813.
- Alternately, you may submit your completed the application in person or by mail. Use the office locator tool to find the address or phone number for a nearby Department for Children and Families (DCF) office.
- If you need help with the application process, contact DCF toll free at 1-888-369-4777.
Controversy around KanCare
In 2010, Kansas began researching options to reform its Medicaid program to improve health outcomes and control costs. In November 2011, the Brownback administration announced its plans to move all Medicaid beneficiaries, including fragile populations like disabled individuals and nursing home residents, into managed care programs. The reformed program was given the name KanCare.
In September 2014, Democrats on the KanCare Oversight Committee requested an investigation of the contracting process with the three managed care companies that participate in KanCare. Those requesting the investigation cited reports that the FBI interviewed numerous people involved in the contracting process. In October 2015, Amerigroup, one of KanCare’s three managed care organizations, hosted a fund raiser for Republican members of the Senate Health and Welfare Committee, which oversees KanCare’s performance. The fund raising continued a trend of financial contributions to lawmakers from the private companies that contract with KanCare, and calls into question lawmakers’ willingness to provide meaningful oversight for KanCare’s performance.
Another area of concern was raised by a study conducted by the University of Kansas. Researchers found that nearly half of disabled individuals interviewed had problems accessing services through KanCare.
Finally, a former employee of one of the managed care companies that participates in KanCare has filed a lawsuit alleging fraud. Jacqueline Leary filed suit against Sunflower State Health Plan, and its parent company, Centene. Leary alleged she was wrongfully terminated after reporting potential fraud with her former employer’s network contracting practices for KanCare business. The lawsuit was dropped in July 2015.