TOPEKA, Kan. — Democratic and moderate Republicans lawmakers worked together last year to try to make Kansas the latest state to expand Medicaid, only to see their bipartisan effort rewarded with a veto from former conservative GOP Gov. Sam Brownback.
The election this month of a governor who supports Medicaid expansion seemed to remove the biggest hurdle for those hoping to bring health coverage to thousands of the state's poor. But it's not that simple.
In the same election that put Democrat Laura Kelly in the governor's office, Kansas voters also elected a more conservative Legislature. Any bill seeking to expand Medicaid will have a tougher time getting to the governor's desk.
"I'm still looking at every possible way that we can stop that," said state Rep. Dan Hawkins, a conservative Republican from Wichita who is chairman of the House's health committee.
Republicans retained their large majorities in both chambers and will appoint the leaders of the committees, who can help them bottle up or kill legislation they don't like. In this month's election, conservatives gained at least half a dozen seats in the House and might replace the chamber's majority leader, a moderate, with someone who leans further to the right. Hawkins is vying for the post.
In the Senate, the health committee chairwoman is a moderate Republican who was instrumental in pushing Medicaid expansion last year but is leaving her position after being elected state insurance commissioner. Her replacement is likely to be more conservative.
With conservatives in control of the majority party, Kelly will likely have to make concessions on Medicaid expansion to get enough support to pass the Legislature. One could be a work requirement for recipients, something other Republican-leaning states have imposed.
For her part, Kelly, a veteran state senator from Topeka, has promised to have a working group create a bipartisan plan.
"I'm not exactly sure what it will look like yet," she told The Associated Press recently. "I'm a fiscal realist, and I need to make sure whatever we present is doable."
Medicaid provides health coverage for lower-income and disabled Americans, including 377,000 in Kansas, and is funded jointly by states and the federal government.
Thirty-five states have expanded Medicaid under the health care law signed by former President Barack Obama. Voters in Idaho, Utah and neighboring Nebraska approved expansions earlier this month.
In a 36th state, Maine, voters approved an expansion in 2017, only to see their Republican governor stymie it. But the newly elected Democratic governor promised to move ahead.
In Kansas, Brownback and departing Republican Gov. Jeff Colyer were the biggest reasons for the state not expanding the program. Both cited the cost of providing coverage to as many as 150,000 more people.
A much-disputed study for Brownback's administration in 2015 suggested the state's costs could reach more than $100 million a year. Some projections after that were lower: In 2018, Colyer's budget office estimated a net cost of $22 million for the fiscal year beginning in July 2019.
The federal government paid the full cost of covering the expansion group until 2017 and will continue paying 90 percent starting in 2020.
Voters in Oregon, which approved the expansion early, approved taxes on hospitals, health insurers and managed care companies to pay for the program. In Montana, voters this month rejected a ballot measure that would have raised tobacco taxes to extend the state's Medicaid expansion.
"We don't want to take on something that we know is absolutely unaffordable and will require a tax increase," said Kansas Senate President Susan Wagle, a conservative Wichita Republican.
But supporters point to the closing of a small nonprofit hospital in southeast Kansas — after a closing in another town in the region in 2015 — as a cost of not expanding Medicaid. Kelly said providing health coverage to more Kansas residents is "a moral obligation."
Advocates also contend that expanding Medicaid in Kansas would reduce expenses associated with uncovered medical care, reduce the costs of some state programs, make it easier for some people to hold jobs and promote employment in health care.
The Kansas Hospital Association projects a net gain for the state.
"No, it's not going to be easy, but it is easier from the standpoint that we have a governor who is going to push for it," said Kansas Senate Minority Leader Anthony Hensley, a Topeka Democrat.