Why Sam Brownback's Still Opposed to Medicaid Expansion

The Kansas Hospital Association has a ticker on its website showing the amount of federal money Kansas has passed up by not expanding since January 2014. It's nearing $738 million, or about 12 dollars a second.

By Bryan Lowry

Gov. Sam Brownback hasn't joined the chorus of people calling for Medicaid expansion after the announcement that Kansas will lose its first hospital in nine years.

The Mercy Hospital system plans to close its hospital in Independence next month in part because of the state's reluctance to expand Medicaid, which provides health coverage to poor and disabled Kansans.

Kansas is one of 20 states that has resisted expanding Medicaid under the federal Affordable Care Act. Supporters of expansion say they hope news of the closure will spur the Legislature to act and extend Medicaid to 150,000 Kansans who now have no health insurance.

But they say any expansion proposal would need Brownback's support to gain traction.

"I don't think we have the resources to get it done," Brownback told students at Hutchinson Community College last week. He described how the state's Medicaid costs have grown even without expansion.

The federal government has said it will pay 100 percent of the costs of states' Medicaid expansion through 2016, then phase down to 90 percent of the costs by 2020.

The Kansas Hospital Association, which has sought expansion, has a ticker on its website showing the amount of federal money Kansas has passed up by not expanding since January 2014. It's nearing $738 million.

"I think we figured out it's about 12 dollars a second," said Tom Bell, the association's president.

Brownback's secretary of health and environment, Susan Mosier, helped stall a bill to expand Medicaid last session when she testified that it would cost the state $2.4 billion over 10 years, a figure that advocates dispute because it includes costs apart from expansion.

A hurdle for the hospital association to overcome in the coming session is "this idea that we don't have the resources," Bell said, adding that other states have shown expansion helps state budgets because it spurs the economy and some of the Medicaid dollars can go toward programs that previously were funded with only state dollars.

Bell called winning Brownback over crucial and said the Independence closure gives a face to the issue.

Brownback disputed that the hospital closure was prompted by the state's inaction on Medicaid, pointing instead to the Affordable Care Act. "They should blame it on Obamacare. That took a bunch of money out of Medicare, which our hospitals here are far more dependent on Medicare than they are on Medicaid," Brownback said.

"I don't know that particular hospital on Medicare versus Medicaid formulas, but I know most of our hospitals in the state, they lose big when we take money out of Medicare, which has a higher reimbursement rate than Medicaid," Brownback continued. "And many lose money on each Medicaid client. I don't know their particulars, I know that's true of many Kansas hospitals."

Joanne Smith, spokeswoman for Mercy in Independence, said that expanding Medicaid would have brought the hospital an estimated $1.6 million in additional annual revenue. "And that's very significant for a small hospital like ours," she said.

"It was a piece of the puzzle for sure," Smith said. But she also said that shrinking reimbursement rates from Medicare and private insurers, a trend for years even before the ACA, plus high physician turnover and Independence's declining population all played a role in the decision to close.

Independence, with a population of more than 9,000, will become be the largest community in Kansas without a hospital. The closest hospitals are in Neodesha, about 16 miles away, and Coffeyville, about 20 miles away.

"If I have an emergency situation and I need care right now, a very frightening thing is to have to get on the highway and drive at breakneck speeds to a town that's 20 or more miles away to get to an emergency room," Bell said.

The 'Real Issue'

Brownback could have expanded Medicaid on his own, but he signed legislation in 2014 that requires an act of the Legislature to do so. Senate President Susan Wagle, R-Wichita, has said in the past that she's open to the idea based on her experience as a cancer survivor. House Speaker Ray Merrick, R-Stilwell, on the other hand, has taken a hard stance against it.

"The real issue here isn't Medicaid expansion; the real issue is Obamacare and the disastrous effects it's having on this country," Merrick said in an e-mail Friday. "I stand with the majority of Kansans who oppose expanding that disaster in Kansas."

He also expressed concern that expansion would be costlier than estimated and that the federal money for it would disappear in the long term. Senate Vice President Jeff King, R-Independence, whose district includes the hospital, has voiced support for expanding Medicaid in a way similar to that of other red states. His comments generated significant media coverage last week, but he said his position is not new; he would have voted for a red state model of expansion last session.

The closure of Mercy may bring a "greater focus on the fact that expanding Medicaid -- with a Kansas-based solution -- is one way to help fight the health care crisis not only in rural Kansas but in our urban and suburban areas as well," King said.

Several Republican-leaning states have expanded Medicaid in ways that could serve as a model for Kansas, King said. Arkansas used federal money to buy private insurance for more than 200,000 low-income individuals. Indiana expanded Medicaid under a plan that required some enrollees to contribute to health savings accounts.

"If it's just expanding Obamacare, that's going nowhere," King said. "The governor and his staff have to be comfortable with the approach that's taken."

King said Republicans wish they were back in the health care system before Obamacare, but they face the question of what they can do for the betterment of health care in the state, "and the governor's vision in that is vitally important."

Not 'Crying Wolf'

Rep. Sue Concannon, R-Beloit, an outspoken supporter of expansion, said the governor has repeatedly moved the goalposts for what it'll require for him to support it.

"The governor, lieutenant governor and the staff has repeatedly said, 'We're looking for a Kansas solution.' But I haven't seen any -- not one -- solution offered," said Concannon, who serves as vice chair of the House Health and Human Services Committee. "And while part of the world is playing politics, we've got providers in our state who are just trying to provide health care. And we are not crying wolf when we say this is hurting our hospitals."

Eileen Hawley, Brownback's spokeswoman, said in an e-mail that the governor has consistently set three conditions for Medicaid expansion in Kansas. Any plan must be budget neutral and include a work component. Also, the state must provide services for eligible disabled Kansans on waiting lists "before expanding coverage for able-bodied Kansans," she said.

"We should focus on empowering Kansans to have greater economic security, not trap them in a cycle of dependency on government," Hawley said. Concannon said she worries that the Mercy closure "is just the tip of the iceberg." Although she is hopeful it'll rally support for expansion, she is skeptical that House leaders will allow a Medicaid expansion bill to come to the floor.

Bob Beatty, a professor of political science at Washburn University, said the Mercy closure could be a wake-up call for some lawmakers because "it's the difference between 'what could happen' and 'it did happen.' "

Since Brownback, in his second term, won't have to run for re-election, one question facing him is his legacy as governor, Beatty said.

"Do you want to be remembered as the person who sort of surprised people and essentially saved a bunch of hospitals across Kansas?" Beatty said. "Or do you want to be remembered as the governor who really stuck to the conservative principles and did not waver from them in those eight years?"

(c)2015 The Wichita Eagle