Kansas: Lo and behold! Medicaid expansion passes state House...with one ugly catch

Nearly two years ago, normally deep red Kansas came within a whisker of pulling off the impossible:

Kansas House fails to override Brownback Medicaid expansion veto

The effort to expand Medicaid in Kansas fell apart Monday as the House failed to override Gov. Sam Brownback’s veto of a bill that would have expanded the health care program to thousands of low-income people in the state.

The 81-44 vote, three shy of the 84 needed to overcome the governor’s opposition, effectively ends the Medicaid expansion push in Kansas after it successfully passed both chambers with bipartisan support earlier this year.

That was then. This is now. Kansas now has a Democratic governor who supports Medicaid expansion, and yesterday this happened (via Jim McLean of the Kansas News Service):

A coalition of Democrats and moderate Republicans powered past objections from conservative leaders in the Kansas House Wednesday to approve Democratic Gov. Laura Kelly’s Medicaid expansion proposal.

...During a debate that stretched from midday into the evening, the coalition prevailed in a rules fight and fought off several amendments aimed at making the bill more palatable to conservatives before voting 70-54 to advance it to a final vote on Thursday.

...In summary, the bill would:

• Expand KanCare, the state’s privatized Medicaid program, to cover Kansans earning less than 138 percent of the federal poverty level — $17,236 for an individual or $35,535 for a family of four. The Kansas Health Institute estimates that 90,000 of the 130,000 Kansans expected to enroll would be non-disabled adults who are not currently eligible for KanCare. The remaining 40,000 would be children.

• Require the Kansas Department of Health and Environment to refer all non-disabled adults who are unemployed or working fewer than 20 hours a week to a job training program.

It's important to note that this is not the same as a work requirement--it sounds like they'd just have to enroll in a job training program. The description doesn't say whether they'd have to actually complete the program or what, but...whatever.

There is one big turd in the punchbowl, however:

...An amendment added to the bill at the urging of Rep. Troy Waymaster, the Republican chair of the House Appropriations Committee, would also help defray expansion costs by requiring beneficiaries to pay $25 a month for their coverage. Family premiums would be capped at $100 a month. Waymaster estimated the payments would generate between $26 million and $45 million a year.

As Dave Anderson noted via Twitter, this is...not good:

This is a higher premium than CSR Silver benchmark at 100% FPL

(right now single individual earning $12,400 pays $21/month for benchmark Silver and likely to see a $0 to $15/month option in Kansas due to subsidy formula depends on spreads not levels ) https://t.co/ibvReV3i6F

— David Anderson (@bjdickmayhew) March 20, 2019

Family of 4 at 100% FPL and $100 monthly premium would be paying 4.7% of family income for the premium. Much worse than ACA benchmark... might be a good deal for high utilizers but deterrent to healthy/low cost.

— David Anderson (@bjdickmayhew) March 20, 2019

Right now, ACA exchange enrollees earning 100-133% FPL have to pay 2.08% of their income for a benchmark Silver plan. Granted, Silver plans typically include around a $4,000 deductible, but CSR covers all or nearly all of that. For instance, for the benchmark Silver plan, a single 40-year old adult living in Leavenworth County, Kansas would pay:

• $506/month w/$6,000 deductible & a $7,900 out of pocket max if they earned $50,000, but
• $21/month w/NO deductible and a $1,000 out of pocket max if they earned $12,490 (exactly 100% FPL).

I could see making those earning 100-138% FPL pay, say, $10/month or whatever...but $25/month for all expansion enrollees honestly does seem worse than the current situation...at least for those in the 100-138% range, anyway. I don't know enough about how comprehensive Kansas' Medicaid program is, however...they'd still have that $1,000 out of pocket maximum to contend with, so if KanCare doesn't require any co-pays/co-insurance, it might still be a better deal even for those folks.

UPDATE: It's worth noting that even if the $25 premium amendment ends up being included in the waiver request, it doesn't guarantee that it would be approved, even by Trump's CMS Administrator:

I don’t think CMS wld allow that high premium on <100% FPL, although they’d probably allow over 100%. And iirc they have never approved a large premium for those <50% FPL. Indiana charges premium at all FPL levels for plus plan, but ACA EHB plan available w/only copays if <100%.

— Johnathan Grant (@johnathang) March 21, 2019

As I noted last May, even Seema Verma seems to have a limit on how cruel she's willing to be:

In a letter on Monday, CMS Administrator Seema Verma told Kansas officials that her agency would not approve the state’s request to impose lifetime limits, which would have capped a person’s eligibility at three years, after which they could no longer be covered by the program.

Of course, if that happened, it's conceivable that Kansas' Medicaid expansion wouldn't happen at all.

It's also important to note that right now, non-ACA KanCare charges premiums of $20 - $50/month for families earning 166 - 241% FPL...which means the $100/family proposal would be more draconian at a lower income threshold, which is...insane.

As for those below 100% FPL...well, they don't have any viable options right now.