The key to passing Medicaid expansion may not necessarily be our polarized legislature, but voters themselves, especially in small town and rural Kansas. But how much do average Kansans honestly care about expansion, and how much do they prioritize what their communities might gain from it? Maybe less than you think, which might help explain why Topeka is gridlocked on this issue.
Most polling over time shows that Kansans support expansion. For example, the fall 2017 Kansas Speaks survey showed that Kansans supported “expanding Medicaid under the Affordable Care Act” 69 percent to 30 percent—typical numbers in Kansas polls. The exception is one recent poll from a conservative organization that produced 54 percent opposition after crafting their survey questions to make expansion look unattractive.
Unfortunately, no public poll of Kansans has asked how much they actually care about expansion or prioritize it versus other issues. The gut sentiment of most Kansans may be to support expansion, but we do not know the strength of those opinions, or how persuadable they are to opposing expansion. Big unknowns.
One key argument of expansion advocates is that Medicaid expansion would particularly benefit rural communities since the uninsured are often more rural and expansion dollars would benefit struggling rural hospitals. But one pattern in surveys is that rural residents typically support expansion less than suburban and urban residents, and are often pretty divided on the issue.
Elections reflect this.
In 2018, Nebraska, Utah and Idaho voters expanded Medicaid. These states in polls are typically more Republican and conservative than Kansas. If voters there passed expansion, Kansans probably would, too. In all three, though, rural communities mostly opposed expansion. It passed because of suburban and urban voters.
In Kansas, Independence and Fort Scott have experienced hospital closures. However, voters in both often prefer anti-expansion politicians. They backed anti-expansion Kris Kobach strongly in 2018 over pro-expansion Laura Kelly, supporting him as strongly as they supported anti-expansion Sam Brownback in 2014.
When the Kansas state House voted recently to expand Medicaid, anti-expansion votes skewed more toward rural legislators whose communities could benefit more from expansion. Why? Some legislators may feel safe opposing expansion if they believe that constituents will not punish them. That could also explain why conservative leadership blocks expansion votes if they feel that they have nothing to fear.
Barring some grand bargain in Topeka, how does Kansas eventually pass expansion? Advocates bear part of the burden. They should assess how effective their efforts have been. If many Kansans, especially in rural communities, are not voting based on this issue, then how effectively have advocates communicated the benefits and importance of expansion?
Politicians, especially pro-expansion moderate Republicans, also have some burden. Because of changing demographics between the parties, Democrats are increasingly a suburban to urban party, whereas Republicans are increasingly a rural to suburban party. All things equal, Democrats are more likely to defeat Republicans, moderate or conservative, in suburban than in rural districts.
For expansion advocates to replace rural anti-expansion politicians, that probably has to occur in Republican primaries where issues often matter more since party is not a factor. However, moderate Republicans leave many rural conservatives unchallenged in primaries, perhaps thinking that rural voters are too conservative to elect moderates when in fact many pro-expansion moderates represent rural districts.
If voters, especially in rural communities, are not invested in expansion or offered attractive candidates for their palates, then elections will not produce the right mix in Topeka to break its gridlock. Ultimately, most Kansans may support expansion, but they must truly invest in the issue for that preference to become policy.
Patrick R. Miller is an Assistant Professor of Political Science at the University of Kansas.
