Hospital leaders express the same concerns heard in Florida, Alabama, and elsewhere since the midterms: refusing to expand Medicaid to the working poor leaves thousands without coverage, and they still come to emergency rooms for routine care. The problem is, the Affordable Care Act assumed that expansion would be universal, and funds to care for the uninsured have dried up.
The pattern has become familiar since the midterm elections: hospital groups, unable to withstand the loss of funds that paid them to care for the uninsured, are pressing state Republican lawmakers to expand Medicaid for the working poor—a change that would bring federal matching funds and much-needed revenue.
This week, the fight came to Kansas. That’s Kansas as in home to Gov Sam Brownback, among the most conservative state executives in the nation. But it’s also the same Gov Brownback whose KanCare program, a system of Medicaid managed care, caused all 3 contractors to lose millions in its first year. KanCare proved a headache in the governor’s re-election contest in 2014, but a state House panel dismissed an ethics probe.
Fitting a pattern seen in Florida, Alabama, and elsewhere in 2015, hospital leaders in Kansas waited for the 2014 midterms to come and go. Then, they launched their campaign to convince GOP lawmakers that Medicaid expansion is necessary to hospitals’ financial survival.
The message sounds somewhat like the pitch in Florida; that campaign is being promoted by the state’s business community as a tool for economic development. Kansas’ Vision 2020 Committee, led by Tom Bell, president and CEO of the Kansas Hospital Association, and leaders from the state’s largest health system say Medicaid expansion will extend coverage to another 169,000 residents, including 100,000 who are already working.
Expansion supporters are working with Tom Sloan, a Republican committee chairman from Lawrence, on a plan that would include specific plans to raise any state dollars needed to match the federal. (Under the Affordable Care Act, the federal government pays the full cost of expansion to 2017 and 90% after that.) This responds to a key argument from expansion opponents, who say the state cannot afford to extend benefits to able-bodied adults. According to published reports, Bell’s legislation would give the governor the ability to negotiate a waiver directly with CMS.
In Kansas, Medicaid is a $3 billion program that covers 368,000 poor and disabled citizens. The state will not cover able-bodied adults without children. Parents do not receive coverage unless their incomes fall below the federal poverty level. Under ACA, insurance subsidies are available for families but only at or above the poverty level, which is $23,850 for a family of 4.
As the ACA moves into its second full year, hospitals in states that did not expand Medicaid are feeling financial pain on 2 fronts. Because the law envisioned universal expansion, before a US Supreme Court ruling let states opt out, it phased out funds paid to hospitals to cover the uninsured. The mission was to get the working poor covered directly and encourage them to seek preventive care, instead of using the emergency room for routine care.
But in states where lawmakers or governors refused to extend Medicaid to those up to 138% of the federal poverty level, these residents are shut out of ACA coverage. To no surprise, they are using the emergency room as they always have. Affected hospitals—many in rural areas—no longer have revenue streams to fund this care. And after more than a year, the strain is deeply felt. Kansas hospital leaders have pointed to this problem as a chief reason to embrace expansion.
In Florida, this has been a prime motive behind the effort to encourage the legislature to expand Medicaid, perhaps with a waiver requiring recipients to get a job or show efforts to do so. Alabama’s recently re-elected governor has expressed willingness to consider a work requirement.
Bell told the Associated Press that hospitals would consider a special tax to raise the state's matching funds, because they feel it’s worth it to get the additional federal dollars. But many Republicans in Kansas do not want to be associated with anything involving the Affordable Care Act.
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