The state of Kansas remains one of only 10 states that have refused to expand access to Medicaid under the Affordable Care Act (ACA), due in large part to resistance from state Senate President Ty Masterson (R). Now the senator is using his new position as national chair of the American Legislative Exchange Council (ALEC) to continue the fight across the country.
After his appointment on November 30, Masterson wasted no time in denouncing Medicaid expansion on a right-wing radio show. Koch-backed groups like ALEC and Americans for Prosperity (AFP) back Republicans who oppose the ACA option of raising the income limits for Medicaid eligibility on the grounds that it will condone dependency on the government, threaten the private insurance industry, and lead to increased wait times for healthcare services.
But as Medicaid expansion gains momentum in Southern states that have so far resisted it, Masterson faces an uphill battle as a national naysayer. On February 27, in what the Washington Post calls “a landmark shift in healthcare policy,” Mississippi’s Republican-dominated House Medicaid Committee advanced a bill to expand the program there.
Still, ALEC and its affiliated lawmakers remain staunchly opposed to expanding Medicaid to provide health coverage to almost all adults with incomes up to 138% of the federal poverty level (or $20,120 for a single adult in 2024). Under the ACA, states have been encouraged to expand their Medicaid programs with help from the federal government, which picks up more than 90% of the tab for providing more low-income residents with healthcare coverage.
ALEC’s second largest known benefactor (after the Bradley Foundation) is Charles Koch, who gave just over $2 million between 2017 and 2021 through his personal foundation and Stand Together Fellowships, formerly known as the Charles Koch Institute. Koch’s political operation opposed the ACA and fought for its repeal.
ALEC’s Decade-Long Fight
ALEC has opposed Medicaid expansion since it first took effect in 2014 in 26 states and the District of Columbia, providing state legislatures with a “model bill” that requires legislative approval before states raise the income limit for receiving Medicaid benefits.
In January, Kansas Governor Laura Kelly (D) sought that approval when she included Medicaid expansion in her proposed budget for next year. It directs the state to expand Medicaid by January 2025 and tap into additional federal Medicaid matching funds made available by the American Rescue Plan of 2021 (ARP), which offers an additional 5% in the federal matching rate for two years for holdout states to adopt expansion.
Since becoming governor in 2019, Kelly has proposed Medicaid expansion in previous budgets and legislation, but so far her requests have failed to pass in the Republican-controlled legislature.
As for the governor’s latest proposal, Masterson boasts that he “100% believes that we’ll hold the line” in keeping Kansas from expanding healthcare coverage for its low-income residents.
Speaking as national chair of ALEC, he says that it is inaccurate to believe that Medicaid expansion provides healthcare for more pregnant women, the disabled, and the working poor. Instead, he argues that what it actually does is “displace” those groups by “expanding Medicaid — welfare — to able-bodied adults between 19 and 64.”
But after reviewing more than 600 studies in 2020 and 2021, the healthcare advocacy group KFF — a leader in the effort to expand Medicaid to the 2 million people nationwide who fall in the coverage gap — “concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers.”
Expanding the program has led to lower mortality rates and improved outcomes among people with a number of chronic diseases, and better outcomes in sexual, reproductive, and behavioral health.
Kansas is not the only northern state to deny coverage to those living just above the poverty level. In Wisconsin, Governor Tony Evers (D) included Medicaid expansion in his biennial budget proposal for fiscal years 2023 and 2024.
But last May, the Republican-controlled legislature — led by State Assembly Speaker Robin Vos, a former member of ALEC — approved a budget that excluded funds to expand the program and cover an additional 89,700 Wisconsin residents, according to the state’s Department of Health Services.
Koch’s Role
ALEC is not the only Koch-funded group leading efforts to stop Medicaid expansion. AFP, Koch’s astroturf political advocacy group, is also lobbying hard against it.
In an op-ed, AFP-Kansas State Director Elizabeth Patton argues against “Big Government” interference in the healthcare industry, suggesting instead that Kansas should get rid of “unnecessary regulations on hospitals, doctors, and innovators that merely drive up healthcare costs for everyone.” She calls Medicaid a “broken system” in need of “reform” and advocates for expanded telehealth services and access to out-of-state doctors and nurses.
But as KFF points out, Medicaid expansion would enable 82,700 uninsured nonelderly residents of Kansas to be eligible for coverage, which accounts for 38% of the state’s uninsured nonelderly adult population. AFP’s vague proposals fail to account for the impact of a large uninsured adult population on the state’s healthcare system overall.
Using almost identical language, AFP-Wisconsin makes the same argument as Masterson does when speaking on ALEC’s behalf. “By throwing able-bodied, childless, working-age adults onto an already strained — oftentimes broken — health system, Gov. Evers risks the needs of Wisconsin’s most vulnerable,” the very people the program was originally intended to serve.
In its statements, AFP-Wisconsin does not provide any evidence of that having occurred in any of the 40 states and District of Columbia that have already expanded Medicaid coverage for their low-income residents between ages 19 and 64.
Kansas and Wisconsin are the only northern states that have yet to expand their Medicaid coverage. The remaining states still resisting expansion are Southern trifecta states where Republicans control both chambers of the legislature along with the governor’s office. However, legislative leaders in Mississippi, Alabama, and Georgia are finally taking another look at Medicaid expansion.
As KFF reports, “North Carolina expanded Medicaid in December, after a years-long lobbying campaign by the state’s Democratic governor and hospital industry persuaded the Republican-controlled legislature to pass a bill.” That move “may have helped thaw opposition in Alabama, Georgia and Mississippi, …which could lead to new insurance coverage for more than 650,000 people.”
In Mississippi, the Republican-led House passed a bill in February 2023 to expand Medicaid. AFP-Mississippi opposes the bill and thanked the legislators — many affiliated with ALEC — who voted against it. Governor Tate Reeves (R) also opposes the bill, but is quickly becoming a lone voice in the state.
In recent years, certain ALEC lawmakers have begun to support Medicaid expansion once GOP legislative leaders in their state reconsider it.
In Alabama, Republican House Speaker Nathaniel Ledbetter, an ALEC member, claims that too many rural Alabama hospitals are closing because of uncompensated care. He also points out that Alabama has a low workforce participation rate of 57% because some people fear that by working they would lose their Medicaid coverage. He is interested in repurposing Medicaid dollars to help uninsured residents purchase private insurance, but the state would need approval from the federal government to do that.
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