On Medicaid Misinformation and Missed Opportunities

[When my own west Wichita representative in the Kansas House, Dan Hawkins, laid out some misleading and vaguely paranoid claims about Governor Laura Kelly's push for Medicaid expansion in Kansas, I knew what my next Insight Kansas column had to be about. Here, as tend to do, is a slightly longer and updated version.]

With the end of sine die on Monday afternoon, the 2022 Kansas legislative session has finally, officially, come to an end. As Clay Wirestone put it in the Kansas Reflector, it could have been worse. Still, once again, Medicaid expansion didn’t pass, and that's a frustration.

True, the legislature took the the important step of expanding the postpartum health coverage offered by KanCare to new mothers, an action which found support from Republicans and Democrats alike. But the money for that additional aide comes from the state’s own budget, not money which the federal government would provide, as would be the case with Medicaid expansion. The fact that this health care reform has nearly 80% popular support among Kansas voters, yet continues to face opposition from the majority of the Republicans those same voters elected to control the legislature, is a puzzle. Party polarization is one explanation; ideological divides that allow cultural issues to dominate media narratives and voters' headspace is another. And then there is the misinformation about Medicaid expansion frequently spread by Republican leaders--often intentionally, but also sometimes due to their own confusion.

The traditional conservative line against expanding Medicaid to help those people who have no medical insurance through their low-paying jobs, and cannot afford private insurance, but still aren’t poor enough to meet KanCare’s strict requirements, is two-fold. First, there is the libertarian booga-booga talk of the "risk" that Medicaid expansion "will cost state taxpayers more than initial estimates indicate" (ignoring the fact that those estimates show such drastic savings that even significant cost overruns would leave taxpayers in the black), or that Congress will change the law to put all the financial burden for Medicaid expansion on the states (ignoring the fact that representatives from the 38 states which have embraced Medicaid expansion would vote against such), or old reliable fear-mongering about America's debt levels. Second, there is the allegation that expanding Medicaid would increase the number of “able-bodied” Kansans receiving government assistance, and if one believes in up-from-your-bootstraps individualism, that’s a bad thing. There’s plenty to argue with both of these lines of argument, but at least they reflects a consistent (and for Kansans, familiar) ideology--the libertarianish position that Sam Brownback pushed so hard during his seven years as governor, with what most Kansans recognize today as terrible results.

Of late however, some leading Republicans in our state--perhaps because like Republican gubernatorial nominee Deterk Schmidt wants very much to distance himself from Brownback's legacy?--have taken to making what can only be called a pro-welfare argument, claiming that by fighting Medicaid expansion, they are actually the true defenders of Kansas's poorest and most needy citizens: specifically, the disabled already on Medicaid. Representative Dan Hawkins, the Republican majority leader in the Kansas House, recently made this case, insisting that in states which have expanded Medicaid (a total of 38 so far, including every state that borders Kansas), high enrollments have “crowd[ed] out other state budget priorities,” lengthened waiting lists, and left those states with “less to spend on things like education and public safety.” These claims either lack proper context or are outright wrong.

It is true that Medicaid enrollments in the states which have expanded their programs have been far higher than anticipated, especially during the pandemic. But the evidence for Rep. Hawkins’s claims about Medicaid expansion forcing cuts in other sorts of welfare support is very thin. Medicaid expansion, it must be remembered, was part of the overall reform of American health care which the Affordable Care Act created over a decade ago, and ties by law (and thus, of course, to the political interests of every elected representative from those states who accept it!) federal resources to state expansions of Medicaid. Admittedly, those ties require some changes in Medicaid policies, and those bring with them some other statutory costs. But still, when the non-partisan Commonwealth Fund conducted a very extensive review of the budgets of all the states which have expanded Medicaid and aligned their health care policies with the ACA's insurance exchanges and more, their conclusion was that the budgetary burden of traditional Medicaid payments in most states actually declined, even with higher than estimated enrollments. It also determined that the statutory costs which came along with national ACA requirements simply were almost never significant enough to require spending cuts or tax increases for states to maintain existing programs and a balanced budget.

Hawkins’s warning about ill people dying while on Medicaid waiting lists in expansion states sounds worrisome—until you wonder how many may have died while on waiting lists in non-expansion states. When dealing the health needs of the working poor and disabled, there’s always plenty of frightening statistics available, but pitting those currently receiving KanCare assistance against those Kansans struggling to survive on incomes that put them below the poverty line, but not far enough to qualify under current law, misses the whole point of Medicaid in the first place. Keep in mind that whatever the impact of Medicaid expansion on the insurance policies currently available--thanks to the exchanges set up by the ACA, which Medicaid expansion was designed to be part of!--to low-income Kansans whose jobs put them barely above the federal poverty level, there remain even poorer working Kansans, struggling to survive below the poverty line and yet still not poor enough for KanCare. They're worth caring about too.

Ultimately, when Hawkins writes that “expansion in Kansas will result in the same outcome as it has in every other state where it has been implemented,” he’s actually arguing in favor of a positive change. So my recommendation to anti-expansion, politically conservative Republicans like Hawkins is to stick with their usual anti-welfare,small-government, conservtives-hate-welfare, libertarian arguments, much as they might see political advantages in not doing so. In the end, trying to turn the policy changes which Medicaid expansion would entail for some of those already receiving it into an argument for denying of its benefits to many more, often equally needy people, simply doesn’t work.