"Medicaid expansion would give us a $1 million boost," said John Broberg, Hiawatha's interim CEO, who has lobbied his area's Republican senator to support expansion—without success so far.
Expansion in a solidly red state like Kansas would be a big victory for expansion advocates, following voter approval in November of expansion in Idaho, Nebraska and Utah. It likely would be a financial boost for these states' many rural hospitals, though experts say other factors, such as the Medicare cuts and declining rural populations, also are squeezing these facilities.
A Health Affairs study last year found that ACA Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihood of closure, particularly in rural markets and counties with large numbers of uninsured adults prior to expansion.
But so far only Nebraska has moved ahead with implementing a straight Affordable Care Act expansion to all adults with incomes up to 138% of the federal poverty level, as mandated by the voters in all three states.
In Utah, Republican lawmakers last month overrode voters and passed a skinny expansion for people earning up to 100% of poverty, with a work requirement of 20 hours per week along with an enrollment cap and federal spending cap. In Idaho, where 61% of voters backed the expansion ballot initiative, state House Republicans passed a similar skinny expansion bill Thursday requiring beneficiaries to work. Expansion in those two states could be delayed for months while the CMS considers whether to approve these unprecedented waivers.
In Kansas, however, a bipartisan coalition of House lawmakers overcame stiff opposition from legislative GOP leaders to pass the expansion bill. They used a surprise procedure to replace the contents of an unrelated bill with the expansion provisions.
To appease conservatives, the sponsors tacked on a provision requiring expansion enrollees to pay a premium of $25 per month, up to a maximum of $100 per family. That likely would require a CMS demonstration waiver.
"We're not wild about the premium, because it puts more burden on recipients," said Tom Bell, CEO of the Kansas Hospital Association, which has been pushing for expansion for years. "But expansion would definitely help rural hospitals. We're hopeful this will create momentum to get the process moving in the Senate."
Getting a bill through the conservative Senate may require adding a work provision, said Dr. Robert St. Peter, CEO of the Kansas Health Institute, which has studied the costs of expansion.
"Proponents of expansion now feel a lot of momentum," he said. "If they think they can get everything they want without compromises, why would they welcome conversation on a work requirement? That's what we're waiting to see unfold."
Senate GOP leaders did not return calls for comment. Observers say it could take the rest of the legislative session, which typically ends in early May, to work out a deal.
Opponents argue that expansion would be too expensive for the state, even though the federal government currently is paying 94% of the cost, which will drop to 90% starting next year. They warn that Washington could reduce funding in the future, along the lines of the Trump administration's budget proposal to eliminate expansion funding and chop $1.5 trillion from Medicaid over 10 years.
The Kansas Health Institute estimated the state's cost for expansion in the first full year would be $47.4 million, while the Kansas Hospital Association said that would be offset by about $30 million in increased tax revenue and other economic benefits to the state.
St. Peter agreed there would be significant offsetting benefits to the state, including increased fee payments from Medicaid managed-care plans and federal pickup of costs for certain patient groups that now are fully paid by the state.
"It's hard to imagine putting $722 million a year of additional federal and state dollars into the economy and not seeing increased economic activity as a result," St. Peter said.
Beyond the economics, expansion would provide access to care for tens of thousands of uninsured Kansans, many of whom are working low-wage jobs without health benefits, said Melissa Atkins, CEO of tiny Graham County Hospital, a critical-access facility in Hill City in rural northwest Kansas.
"A lot of farmers in our community truly can't afford care," said Atkins, whose hospital currently is faring well financially after a tough stretch a decade ago. "They don't get preventive services done in a timely way, and their conditions worsen.
She suspects many uninsured people in her area who need care aren't coming in because they're uncomfortable about admitting they can't afford to pay.
"Other states are offering expansion coverage with federal dollars, and we're just leaving it on the table," she said. "We should offer it as well."
Krista Postai, CEO of the Community Health Center of Southeast Kansas, an 18-site clinic in the poorest part of the state, said 30% of her center's 60,000 patients a year are uninsured working-poor people, and that most would qualify for Medicaid expansion.
Enrolling them in Medicaid would enable her staff to get them access to costly preventive services like colonoscopies, needed surgeries and specialty services including cardiology and cancer care. Too many have serious conditions diagnosed and treated when it is too late.
She projects expansion would increase her organization's revenue by $1.1 million a year, enabling her to hire more physicians and case managers.
A long-time advocate of Medicaid expansion, Postai was thrilled about the House vote but remains worried about expansion's prospects in the Senate, having seen it die two years ago.
"I had a little champagne Thursday, not the whole bottle because the legislation has to go all the way through," she said. "But champagne doesn't keep well. I'm kind of worried the fizz will go out of it."