

The Kansas Senate votes to accept the federal Medicaid expansion at the statehouse in Topeka on March 28. (Christopher Smith/For The Washington Post)

— State lawmakers in this deep-red state on Tuesday did what a year ago would have been unthinkable: They voted to expand Medicaid under the health-care law that Republicans here have railed against for years.

Among them was Sen. Barbara Bollier (R), whose support last year for extending the government health program to more poor Kansans was considered so rogue that her colleagues tossed her off a health committee. This month, so many Kansas lawmakers voted for the expansion that they nearly mustered the two-thirds majority needed to block the Republican governor’s expected veto.

The abrupt reversal in Kansas could be the front edge of a larger shift nationally, as state lawmakers absorb the repercussions of congressional Republicans’ failed attempt to repeal and replace elements of the Affordable Care Act.

In Virginia, Gov. Terry Mc­Auliffe (D) on Monday pledged to revive efforts in his state’s Republican-led legislature to pass Medicaid expansion. Georgia’s Republican governor, Nathan Deal, also announced plans to change his state’s Medicaid program. Medicaid advocates in North Carolina see hope for renewed momentum as Gov. Roy Cooper (D) has sought to expand the program there through executive action.

Kansas lawmakers are shrugging off what had long been a concern for critics of the health law: that agreeing to expand Medicaid would make the law far more difficult to repeal because it is politically dangerous to revoke benefits once people have them. In Kansas, the expansion would make 150,000 additional low-income residents eligible for Medicaid. Some of the most vocal critics of the GOP repeal plan were Republican governors of states that embraced the Medicaid expansion for their constituents.

The vote in Kansas comes as politicians in Washington also grapple with the fallout of last week’s health-care battle. House Speaker Paul D. Ryan (R-Wis.) is trying to reassure donors that congressional Republicans will go back to the drawing board as they pressed forward on other aspects of President Trump’s agenda. Democrats, meanwhile, are using the moment to press for improvements to the existing health law and to renew calls for universal health care.

Though Kansas legislators strongly approved Medicaid expansion — the 25-to-14 Senate vote included 16 Republicans in favor of it and 14 against it — Gov. Sam Brownback has signaled he will veto the bill, asserting that the health law will collapse regardless of congressional action.

“To expand Obamacare when the program is in a death spiral is not responsible policy,” spokeswoman Melika Willoughby said in a statement. “Kansas must prioritize the care and service of vulnerable Kansans, addressing their health care needs in a sustainable way, not expanding a failing entitlement program to able-bodied adults.”



Kansas state Sen. Laura Kelly (D) works in her office in the on March 28. She voted in favor of the Medicaid expansion. (Christopher Smith/For The Washington Post)

The vote Tuesday in Topeka was more than just symbolism, sending a clear signal that Republicans nationally are facing new pressure to participate in a program they once saw as one of the 2010 law’s central evils.

[McAuliffe: If Obamacare is here to stay, then it’s time to expand Medicaid]

Medicaid is administered by the states, combining state and federal dollars to provide health services to low-income people, including children and their caretakers, pregnant women, the disabled, the blind, and those over the age of 65 who qualify. The coverage can vary by state, but the federal government requires it to include doctor’s visits and hospital expenses, among other services.

Expanding Medicaid is the Affordable Care Act’s primary mechanism for extending health coverage to millions of previously ineligible low-income adults. Initially, states were required to participate in the Medicaid program, but the U.S. Supreme Court found the requirement unduly coercive and made expanding the program optional.

Over time, 31 states and the District of Columbia opted in, according to the nonpartisan Kaiser Family Foundation, collecting millions of new federal dollars to cover those adults. Nineteen states, including Kansas, turned down the money, unwilling to enlarge a costly entitlement program that required additional financial contributions at the state level. Besides, they said, why sign on to an expansion that they dearly hoped Washington would eventually repeal?

That created what health experts called a “coverage gap” in the states that declined the expansion. Extremely poor parents continued to receive health care under the original Medicaid program, and people above the poverty level could get subsidies to help them buy coverage on the insurance marketplaces. But those in the middle — the poor, non-disabled single people and slightly-less-poor parents — had no options. That group included more than 2.5 million people last year nationwide, according to Kaiser.



State senators Laura Kelly (D) and Barbara Bollier (R) talk after the Senate voted to accept the federal Medicaid expansion. (Christopher Smith/For The Washington Post)

Bollier had long been one of the best-known outliers in her party when it came to Medicaid expansion. A retired anesthesiologist from eastern Kansas, just across the state line from Kansas City, Mo., she said her support was rooted in her concern for poor uninsured patients, who she said often get treatment for acute problems in the emergency room but went without treatment for chronic conditions.

Asked whether she felt vindicated by Tuesday’s vote, she demurred. “I am just elated that we’re now at the point that we can debate this bill,” she said.

Once the bill gets to Brownback’s desk, he has 10 days to veto or sign it. If he does neither, the law automatically goes into effect. Advocates for Medicaid expansion already are mobilizing to whip up the three additional votes in the House and the two additional votes in the Senate needed to override his veto.

The seeds for Kansas’s actions were planted years ago, though proponents of Medicaid expansion say they got a boost from the news out of Washington last week.

Bollier was one of the moderate Republicans elected to the Kansas House and Senate who last year dislodged the grip that hard-line conservatives once held in the legislature. Bollier was elevated from the state House of Representatives to the upper chamber.

Kansas voters had grown weary of severe cuts initiated by Brownback, who pared back income taxes, particularly for the wealthy, and eliminated taxes for about 330,000 businesses, said Burdett Loomis, a professor of political science at the University of Kansas. The state ran out of money to repair highways and its credit rating had been downgraded multiple times, he said.

“In 2016, people finally had enough,” Loomis said. “The experiment wasn’t working.”

[The Daily 202: New momentum for Medicaid expansion, as more Republicans conclude Obamacare won’t get repealed]

At the same time, health-care advocates and hospitals joined forces for a campaign that many credit with helping turn around negative views of the Medicaid component of the Affordable Care Act.

Alliance for a Healthy Kansas, an advocacy group representing dozens of health-care organizations and professionals, cited studies that found that expanding Medicaid would benefit working people and create as many as 4,000 jobs statewide. It emphasized the state’s role in administering Medicaid, which advocates referred to by its local moniker, KanCare.

A January poll by the advocacy arm of the American Cancer Society found that 82 percent of Kansans supported expanding KanCare, a 10-point jump over 2013.

The 2015 closure of Mercy Hospital in Independence, Kan., also was a rallying point. Among the reasons the hospital cited for shuttering was reduced revenue that would have been offset by more Medicaid patients under the health law. The Kansas Hospital Association, which supported expanding Medicaid, warned that other hospitals could similarly fail without government action to ensure that more sick, low-income Kansans had some sort of health-care coverage.

“I think that is exactly what changed the conversation, that we had the closure of a significant rural hospital,” said Sen. Laura Kelly, the top Democrat on the Public Health and Welfare Committee. “What you watched then was the legislators from that area . . . realizing, before an election, that, ‘Oh, my gosh, this is really awful.’ ”

Republican critics of the bill said they are sympathetic to the hospitals’ plight but are reluctant to join a program that they think is flawed.

“I care about my hospitals,” Republican state Sen. Susan ­Wagle said during a floor debate Monday, growing emotional. “But this is a broken program. It’s a broken program, people.”

The pro-Medicaid position has led to a tricky balancing act for some Republicans, considering that opposition to Obamacare has been a central plank in the GOP platform for years.

On his campaign website, freshman Kansas Rep. John Eplee (R) said he believes health policy should be decided by the state and not the federal government. In an interview, he said he remains opposed to the Affordable Care Act. Yet he has been among the more vocal supporters of Medicaid expansion in Kansas.

“This, in my opinion, is not Medicaid expansion in the sense that it is Obamacare,” Eplee said. “It’s a Kansas plan.”



The Kansas State Capitol in Topeka. (Christopher Smith/For The Washington Post)

Somashekhar reported from Washington.