Medicaid Expansion -- Kansas and Mississippi
Ten states, mostly in the South, have not yet adopted the Medicaid expansion. This is the part of the Affordable Care Act that covers uninsured parents, couples, and single adults with incomes of less than 138% of the federal poverty level (FPL) -- $20,783 for an individual, $43,056 for a family of four.
In Mississippi, for example, the current Medicaid eligibility level for parents is 24% of the federal poverty level. https://www.healthinsurance.org/medicaid/mississippi/#:~:text=Adults%20with%20dependent%20children%20are,up%20to%20199%25%20of%20poverty. In Kansas, the current Medicaid eligibility levels for parents are 38% of the federal poverty level. https://www.kancare.ks.gov/docs/default-source/policies-and-reports/kdhe-keesm/appendix/financial/f-8-ks-medical-standard.pdf?sfvrsn=2f81511b_36 Neither state offers Medicaid coverage for single adults or couples without dependent children living at home.
The Affordable Care Act (ObamaCare) offered coverage for the nation’s uninsured in two ways: subsidized individual coverage for the uninsured with incomes over 138% of FPL and expanded Medicaid coverage to cover the uninsured with incomes under 138% of FPL. These options are available to the uninsured who do not have coverage through their workplace or other coverage.
Medicaid was a program initially passed in 1965 to provide health coverage to low-income uninsured Americans; it was linked to the welfare categories (aged, disabled, blind or single parent families with dependent children); this was known as categorical eligibility. It was slowly expanded during the 80’s and 90’s to cover more children, more parents, and more pregnant women. In 1995, the federal government ended the AFDC program for needy parents and their dependent children and replaced it with a block grant to states called TANF (Temporary Assistance to Needy Families). By the mid and late 90’s in California, those eligible for Medicaid through “welfare status” were only a fraction of Medicaid’s overall program enrollees. Program spending has always been primarily focused on those with the greatest health needs – the aged and disabled, particularly those in long term care (nursing homes).
Medicaid requires a state funding match that varies from as low as 50/50 in high income states to as high as 83/17 in low-income states. Arizona was the very last state to adopt Medicaid in 1983. It did so with a Section 1115 waiver that allowed for mandatory enrollment in managed care and coverage of indigent uninsured adults. These waivers allow states the flexibility to experiment with improvements in their Medicaid programs, provided they are cost neutral to the federal government.
Under the original federal Medicaid law, certain categories of low-income US citizens were not eligible. In California we called them the MIAs or Medically Indigent Adults. They are also referred to as the working poor because many work at low paying jobs. They were ineligible for the traditional state and federal cash assistance welfare programs such as AFDC, TANF, and SSI. Depending on the state or locality, they may have been eligible for cash assistance under the rubric of General Relief or General Assistance. Some are homeless; some are college students, and some are waiting for a disability determination to be eligible for SSI. Others are unemployed, and the size of this subgroup is particularly volatile, spiking dramatically during really bad recent recessions such as 2008 and 2020. In states as varied as Arizona, Tennessee, Massachusetts, New York, Delaware, Oregon, Connecticut, Wisconsin, Vermont, and others, the state secured a federal waiver (known as a Section 1115 waiver) to cover its MIA population with a federal Medicaid match by agreeing to offsetting Medicaid reforms, such as mandatory managed care, a basic health plan, retargeting of DSH funds, or a global budget.
States such as Massachusetts and California terminated their state only programs for medically indigent adults during bad economic conditions in large part because there was no federal match for this population. This occurred under the leadership of Democratic Governors Mike Dukakis and Jerry Brown — Governors who in later gubernatorial terms pushed hard and quite successfully to cover some or all of the uninsured.
In California, the MIAs were the largest group of uninsured poor. This is very different than Mississippi and Kansas where parents make up a large share of the uninsured poor due to the states’ very low income eligibility thresholds.
Under Republican Governor Mitt Romney, Massachusetts adopted a program to cover the uninsured that prefigured the Affordable Care Act. It expanded Medicaid using an 1115 waiver to cover the low income uninsured, and it created a subsidized purchasing pool for individual coverage of moderate- and middle-income individuals. Like the ACA, RomneyCare had an individual mandate and insurance reforms to prevent insurance companies from excluding individuals with medical conditions ranging from diabetes and cancer to pregnancy. California under then Governor Arnold Schwarzenegger tried to adopt a RomneyCare lookalike but was stymied by progressive Democrats led by state Senator Sheila Kuehl who were wedded to a single payor Canadian style system or nothing.
Under the ACA, states were required to adopt the Medicaid expansion or lose their entire federal Medicaid match. States like Florida and Texas sued, and the Supreme Court ruled the Medicaid expansion was voluntary with the states, reflecting their “sovereignty”.
To reduce the financial burden on state and local taxpayers for extending coverage to the uninsured, the Affordable Care Act set the federal-state match at 95/5 slowly changing to 90/10. Most states saw this financial opportunity and embraced it to cover their low-income citizens. Some did it by executive action, some by legislative action, and others by voter approved ballot initiatives. President Biden further increased the financial incentives for those states that have not yet expanded Medicaid – an enhanced 5% federal match for two years on their entire Medicaid program. Financially, this is a big windfall for states who had not yet covered the low income uninsured by expanding Medicaid. In 2023, North Carolina and South Dakota were the most recent states to adopt Medicaid expansion – one by compromises between the Democratic Governor and Republican legislature and the other by a voter ballot initiative.
Both Mississippi and Kansas are reliably Republican states that have been considering passage of the Medicaid expansion in 2024. Other reliably Republican neighboring states have already adopted the Medicaid expansion for the working poor, including the neighboring Great Plains states of Nebraska, Iowa, Missouri, Oklahoma, North and South Dakota, and the Southern states from the old Confederacy of Louisiana, Arkansas, Virginia, and North Carolina. One would have thought that given their large rural, low income populations with scant and financially stressed health resources and low rates of private insurance in agricultural employment, state legislators would leap at the opportunity to cover their citizens. In states like Mississippi, there are large numbers of uninsured parents who would be helped by the Medicaid expansion because the state’s current Medicaid eligibility levels for parents are so very low.
So, what’s the problem, why don’t they simply pass the expansion? It is largely political. Congressional Republicans opposed the ACA, reviled ObamaCare, and after it was passed, they undertook multiple efforts to repeal it, culminating in the showdown on the Senate Floor where in the face of unparalleled efforts by Trump, Ryan and McConnell to repeal it via budget reconciliation, Senators McCain, Murkowski, and Collins stood firm and voted to preserve the ACA on July 27, 2017. The House GOP paid a heavy political price in the 2018 election cycle for their misplaced efforts to repeal the ACA. Far right extremists under the MAGA flag began to primary the more moderate GOP members in safe seats designed by political gerrymandering and began to change the composition of the Republican Party — a process that further accelerated after Trump’s loss in the 2020 presidential election.
Trump was nevertheless successful during his tenure in repealing the much-hated individual mandate component of the ACA and the federal assistance for outreach and enrollment. Biden was successful in increasing the premium subsidies and improving affordability for individual coverage in the federal and state purchasing pools (Exchanges). (Covered California in our state.) Biden further improved the budgetary incentives for states to approve the Medicaid expansion. The result is the program has become ever more politically popular (60% voter approval) with ever higher enrollment (in excess of 45 million Americans enrolled) and Republican voters’ level of hostility to the program declined.
Candidate Trump in 2023 has pledged once again to repeal the ACA, if elected. https://apnews.com/article/trump-obamacare-health-care-biden-c2b1f5776310870deed2fb997b07fc2c He recently changed his tune saying he now seeks to improve it and make it more affordable. https://www.nytimes.com/2024/04/11/us/politics/trump-biden-affordable-care-act.html
Mississippi Republican voters strongly support Medicaid expansion. https://www.wjtv.com/news/politics/mississippi-politics/new-poll-breaks-down-support-for-medicaid-expansion-in-mississippi/ Kansas voters from both parties likewise strongly support Medicaid expansion. https://sunflowerfoundation.org/poll-shows-strong-support-for-expanding-medicaid-among-small-businesses-voters/#:~:text=The%20poll%20also%20gauged%20respondents,62%25%20among%20Republican%20primary%20voters.
Both states are in the same but very different places and do not have ready access to voter initiatives to bypass legislative inaction.
Mississippi’s Republican Governor Tate Reeves is unalterably opposed to the Medicaid Expansion and threatens to veto the measure if it comes to his desk. Republicans in the Mississippi House and Senate are trying to cobble together a Medicaid expansion that will have two thirds vote in each House, in order to overcome the anticipated Governor’s veto. https://www.clarionledger.com/story/news/politics/2024/04/24/medicaid-expansion-mississippi/73423413007/ One of the sticking points is coverage for individuals in the 100-138% income strata. The Mississippi Senate negotiating team wants to keep them in the federally subsidized purchasing pool for individual coverage where they are now covered, rather than enroll them in the state’s Medicaid program as the ACA envisaged.
Kansas Democratic Governor Laura Kelly is leading her state’s effort to adopt the Medicaid expansion. The state’s Republican legislative leaders are opposed, and they bottled the bill up in Committee. Democratic Minority Leader Dinah Sykes has moved to bring the bill directly to the Senate Floor with the support of all the major interest groups. This is scheduled for a vote on April 25 when the state legislature is back in session. https://governor.kansas.gov/motion-to-vote-on-medicaid-expansion-made-in-the-senate-heres-what-theyre-saying/
Mississippi ranks near the very bottom in coverage, quality, costs, outcomes, and access to health care. https://www.forbes.com/advisor/health-insurance/best-worst-states-for-healthcare/#:~:text=Mississippi%20tops%20the%20list%20of,deaths%20per%20100%2C000%20state%20residents). Its rural hospitals are in danger of closing due to the state’s high percentage of uninsured. Its low-income uninsured face preventable illness and death without the Medicaid expansion. It has a particularly sordid past of segregation and violence to prevent any forward progress for African-American citizens. Medicaid expansion presents an opportunity for the state to cover its uninsured, to build its rural healthcare infrastructure and to take a leadership role regionally in health care. Expansion of Medicaid is supported by the Mississippi Hospital Association, Medical Association, Manufacturers Association and many church leaders. Church leaders have been in the forefront of support for the Medicaid expansion. https://mississippitoday.org/2024/04/08/christian-argument-for-medicaid-expansion/
Kansas ranks in the bottom half to bottom third of states on many health measures. https://www.americashealthrankings.org/learn/reports/2023-annual-report/state-summaries-kansas It compares poorly to the neighboring states of Iowa, Nebraska, and North Dakota, but compares quite favorably to the neighboring states of Missouri and Oklahoma. It has a very high percentage of its vital rural hospitals in danger of closing due to financial distress – a crisis not shared with neighboring states that have adopted the Medicaid expansion. https://kansasreflector.com/2023/12/12/kansas-unrivaled-rural-hospital-crisis-58-at-risk-of-closing-82-lost-money-on-patient-care/#:~:text=The%20health%20policy%20organization%20reports,to%20fold%20was%20Herington%20Hospital. Supporters of the expansion range from the Kansas Hospital Association, to the Sheriffs Association, to disability advocates, to the Kansas City Chamber of Commerce and many others. https://kansasreflector.com/2024/03/21/despite-overwhelming-kansas-public-support-medicaid-expansion-bill-shot-down/#:~:text=Support%20comes%20from%20many%20sectors,county%20jails%20under%20the%20bill In recent polling, more than two thirds of Kansas voters and nearly 80% of small business owners support the proposed Medicaid expansion. https://www.expandkancare.com/new-poll-confirms-widespread-support-for-medicaid-expansion-in-kansas/ Faith leaders from across the political and religious spectrum are urging the legislature to adopt the Medicaid expansion emphasizing for example that a pro-life pro-family agenda does not stop after the child is born. https://kansasreflector.com/2023/11/22/kansas-clergy-place-faith-in-state-legislators-embracing-moral-truth-of-medicaid-expansion/ Kansas small businesses and business leaders are supporting the Medicaid expansion. https://governor.kansas.gov/kansas-businesses-support-medicaid-expansion-during-kansas-legislatures-hearings-heres-what-theyre-saying/ Will this be enough to galvanize a sufficient bi-partisan number of state legislators to put the expansion on Governor Kelly’s desk?
There are two conflicting Republican traditions at play. Republican Presidents, as diverse as Theodore Roosevelt and Richard Nixon and Republican Governors as different as Earl Warren and Mitt Romney have sought universal coverage. Republican Congressional leaders from Senator Robert Taft to Senator Bob Dole to Senator Mitch McConnell have tried to block coverage for all Americans. Their rallying cry was “socialized medicine”, an epithet popularized by the American Medical Association, which meant that the government would run the health system, hire doctors, and own the hospitals as in Great Britain; this is not in discussion in the US. The medical establishment was strongly opposed as well to the Canadian style single payor system where the government pays private hospitals, doctors and others for their patient care from tax revenues. This is an efficient and effective system supported by Senators Warren and Sanders, but again it is not now in play in the US.
In the US, we have a mixed (some say mixed up) public-private system. Medicare pays for seniors and the disabled with designated payroll taxes. Medicaid pays for the poor (or some of the poor) with federal and state general taxes. Employers pay for their employees with pre-tax subsidies, most generous to high wage employment. Individuals not covered through any of the above may buy individual insurance with tax credits graduated to their incomes through the ACA created purchasing pools. Private insurers participate in public programs like Medicare and Medicaid. In California, public health plans also participate and compete. The challenge for state and federal policy makers is to synch up and coordinate these disparate systems so that we have effective and continuity of health care for every American, albeit paid for in a range of different programs. We do not need to move to one size fits all; we do need to move towards effective and efficient health care delivery systems with good to excellent measurable patient outcomes.
Our nation’s uninsured rates range from a low 2-3% in Vermont and Massachusetts to a high of over 16% (one in six) Texans. Medicaid expansion in all 50 states would cover about 1.5 million uninsured Americans, mostly living in the deep South. https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/ Medicaid expansion would cut the uninsured rates in the ten states in half; with the greatest forward progress possible in states like Mississippi and the largest impacts in rural areas and states where wages and incomes are lowest and uninsurance rates are highest. Medicaid expansion will not provide full scope coverage for undocumented workers and their families; that is an undertaking that will need to be considered as a part of immigration reform. It will help low income patients, their providers, the local doctors, hospitals, clinics, and drug stores. Employers will benefit from a healthier workforce. The burdens of hospital uncompensated care will be lifted from those with private insurance. Patients will no longer be sued by their doctors and hospitals for medical debts they have no earthly chance of collecting. It’s a win, win, win.