Suzan Emmons couldn't afford to purchase her own health insurance plan anymore.
Premiums spiked following implementation of the Affordable Care Act, and she didn't qualify for a plan through the marketplace with just $14,000 in annual income from her housecleaning business in Allen County.
Emmons, who is raising two grandchildren, made too much money to qualify for Medicaid in Kansas, where funds for adults are reserved for those who are pregnant, disabled or barely making money.
The ACA, also known as Obamacare, expanded Medicaid eligibility to protect individuals like Emmons who were caught in the coverage gap, but a U.S. Supreme Court ruling made expansion optional. The idea met resistance in Kansas as unsettled cost projections spooked lawmakers.
Now, mounting evidence suggests a massive influx of federal cash and subsequent economic growth would neutralize the state's burden and cushion weakened rural hospitals, but the idea faces ongoing opposition from skeptics.
Alan Cobb, president and CEO of the Kansas Chamber, said nobody really knows what the numbers will be.
"There is no free lunch, and there is no free money, and the cost in most of the states, maybe all of the states, that have expanded has vastly exceeded the estimates," Cobb said.
In 2017, Emmons testified before legislative committees, hoping her personal story would convince those lawmakers to look beyond the numbers on their policy briefs and see a labored caregiver. The Legislature that year passed a Medicaid expansion bill but didn't have enough votes to override the veto of former Gov. Sam Brownback, hardening Emmons' view of the political process.
“They have their heads up their rears," Emmons said. "It’s just look at numbers on a paper and what makes sense to them. I don’t understand why they want to turn their head the other way. They are ignoring what Kansans need.”
Lawmakers who stiff-armed Medicaid proposals in 2018 entered this year's session with the urging of Gov. Laura Kelly to expand coverage, a relatively stable budget outlook and research from a litany of sources who independently report amenable costs for providing insurance to another 150,000 individuals.
Emmons now earns enough to qualify for a marketplace plan and enjoyed health insurance in 2018 for the first time in several years.
She also received her first mammogram in several years, which revealed a concerning spot.
Mercifully, further examination determined the mark wasn't malignant. She wouldn't have been able to afford those tests without coverage, though, and the consequences of abandoning preventative care are startling for someone with a family history of cancer. She felt like opponents to expansion believe people who are poor deserve their misfortune.
“There’s a stigma about welfare — you know, just laying around doing nothing," she said. "It’s not. It’s hardworking Americans who are just trying to make a living. And it makes me angry that they let all this money go.”
Under expansion, the state would pay for 10 percent of the cost of medical service while the federal government absorbs the rest. That amounts to an increase of $1.8 million in federal funds that would flow through Kansas health care providers every day.
Kansas is among 14 states yet to embrace expansion, and five years of resistance already has cost the state more than $3 billion in federal assistance, according to figures tracked by the Alliance for a Healthy Kansas, a coalition of doctors, hospitals, social service providers and faith leaders that lobbies for Medicaid expansion.
"All we’re doing," said alliance director April Holman, "is sending our taxpayer money to those states who have made this policy a part of their state makeup.”
The Kansas Policy Institute is among the naysayers who object to any advancement of Obamacare and dispute prevailing cost analysis. KPI policy director James Franko also asserts that costs always exceed expectations when states deploy Medicaid expansion.
“People of good faith can simply come to different conclusions on this or any other policy question,” Franko said. “We should also be able to agree that a program should be measured on results.”
'A focal issue'
The ACA offers the carrot of higher compensation to states that expand coverage to individuals whose yearly income is less than 138 percent of the federal poverty level — $16,000 for an individual or $34,000 for a family of four.
Studies by the Kansas Department of Health and Environment, Kansas Health Institute, Kansas Hospitals Association and Harvard researchers show 145,000 to 152,000 individuals would sign up following expansion. That includes people who already have coverage through another source, as well as people who don't realize they already are eligible — sometimes referenced as the “woodwork” effect, and a source of bitterness by expansion critics who fear Kansas enrollment will soar beyond prediction.
Robin Rudowitz, the associate director for Kaiser Family Foundation's program on Medicaid and the uninsured, said many states initially discovered more people than anticipated were taking advantage of newly available coverage, but in the long run, the estimates were met. As more states embraced expansion, forecasters are able to better calibrate their expectations, she said.
The 2017 expansion bill expected 150,000 new participants and a $26 million impact on the state budget for fiscal year 2020, which starts in July. That is consistent with a KHI study that shows the state's gross cost would be about $110 million and the KHA assessment that savings would lessen the burden. For example, the state currently pays 45 percent of the medical costs for an uninsured pregnant woman but would be responsible for just 10 percent after Medicaid expansion.
The hospitals group also contends that improved tax collections would eliminate the state's burden entirely. The estimate assumes a modest 5 percent return on federal funds, where other states have seen a 13 percent to 18 percent return.
Based on those figures, KHA president and CEO Tom Bell said he doesn’t understand why some remain so adamantly opposed to expansion.
“Why we are apparently trying to become the last state to do this is beyond me,” Bell said. “I can understand the politics of it, but continuing to make this such a focal issue year in and year out, I don’t understand.”
Late last year, Mercy Hospital in Fort Scott became the most recent Kansas hospital to shut its doors.
Medicaid expansion isn't the only reason hospitals struggle financially, but it is a contributing factor. Without Medicaid expansion, Bell said, more Kansas hospitals could cease to exist.
“I think the answer probably is yes," Bell said, "but I can’t tell you which ones those are, and I can’t tell you that the closure of any particular hospital is 100 percent because of Medicaid expansion. I can tell you that if Fort Scott had been able to count on an extra million bucks from Medicaid expansion, they’d have thought a lot more seriously about whether to close.”
Commercial health insurance carriers traditionally subsidized the cost of caring for patients without insurance, but those carriers no longer see that as their responsibility. In some rural areas, hospitals operated by city and county governments have turned instead to local taxpayers to make up for the lack of coverage, Bell said.
A study released in September by Harvard fellow Anna Goldman and associate professor Benjamin Sommers concluded the uninsured rate of low-income Kansas adults is significantly worse than in other Midwest states that adopted Medicaid insurance. As a result, Kansans report more frequent delays of care, greater difficulty in paying medical bills and worse quality of care.
Scott Taylor, president and CEO of St. Catherine Hospital in Garden City, said his hospital, as a ministry of the Catholic church, has a calling to provide for patients regardless.
But many rural facilities are losing money, he said. By unlocking federal funding, those payments would make a difference in communities where medical providers would be able to hire another practitioner or purchase equipment.
Through the Centura Health network, Taylor works with 600 employees at facilities that serve a 20-county area in rural western Kansas. Expansion would provide them with $3 million in annual revenue, Taylor said, all of which would be invested in new jobs or devices.
He said he believes opposition to expansion is purely political spite for Obamacare. If he could whisper in the ear of lawmakers as they prepare to vote on the issue, he would tell them expansion is the right thing to do for hardworking, low-income Kansans.
“It’s fiscally responsible, and it will improve the health of all of Kansas," Taylor said.
'They'll drag it out'
Franko cautions that economic projections ignore an unseen impact in the form of regulatory distortion and taxes paid by private business.
"Being given a Medicaid card does not guarantee better health outcomes," Franko said. "We should also keep in mind the other ways to increase access and lower health care costs that do not bring more folks onto government insurance — short-term or association health plans are but two things we’ll be working on in 2019."
Franko embraces the Foundation for Government Accountability, source of many of the counter-expansion arguments, as a "great partner." FGA analysis is widely disparaged, however, in by the academic realm.
Assessment of FGA findings by journalists, legislators and a federal judge, as documented by the Brookings Institute, describe FGA information as incompetent, misleading, fundamentally flawed, oversimplistic, exaggerated and irresponsible.
Officials from Indiana, North Dakota and Ohio have contradicted the FGA narrative that every state that expands Medicaid faces a higher-than-expected surge in enrollment. A peer-reviewed study by Sommers found state budget projections to be reasonably accurate.
Franko dismisses the criticism as robust policy discussion between groups with different perspectives.
Cobb, the chamber president, said he also has concerns about expanding a program that many people view as poorly operated.
"There's an agreement you don't have great health outcomes, it's not a great program," he said. "Why spend all this money and effort on something that most folks think doesn't work very well?"
Despite those objections, Holman, the Alliance for a Healthy Kansas director, remains cautiously optimistic that lawmakers will pass expansion this session. She is leaning on a network of people across the state to educate and engage on a grassroots level.
“I think that their personal stories about why this is important to them are going to be, in the end, the most powerful work that is done for expansion,” Holman said.
Emmons, the Allen County grandmother, has a more jaded view. She wonders if the governor will follow through on her talk of expanding Medicaid, or if the Legislature will even send her a bill.
“I’m sure they’ll drag it out as long as they can because that’s what they do,” Emmons said.