Kansas Hospital Association CEO Tom Bell will retire in September after helping push through a hard-fought bipartisan deal to expand Medicaid to an estimated 150,000 adults earning up to 138% of the federal poverty level. The expansion, which would start next January, is expected to ease the rural hospital crisis in his state, where five hospitals have closed since 2010 and another 29 are on the financial brink. Bell, who started with association as legal counsel in 1986 and has served as CEO since 2005, spoke with Modern Healthcare senior reporter Harris Meyer about how the Kansas agreement fits into the national battle over Medicaid expansion. The following is an edited transcript.
MH: What should people around the country take away from the deal earlier this month between Democratic Gov. Laura Kelly and Republican Senate Majority Leader Jim Denning to expand Medicaid under the Affordable Care Act and seek a Section 1332 reinsurance waiver? A previous GOP governor vetoed expansion in 2017 and Denning helped block it last year.
Bell: A Democratic governor and a Republican legislative leader coming together and compromising on a major piece of legislation—that doesn’t happen that often anymore. This is what good government looks like. You go from differences of opinion to dialogue to compromise, and that’s exactly what’s happened here. That in itself is a major story.
MH: What were the key compromises?
Bell: Sen. Denning wanted to first do the reinsurance waiver and the governor didn’t want that to be part of the expansion package. The compromise was we’ll move forward with the waiver but not let that delay the expansion. The senator also wanted a cigarette and vaping tax, but the governor felt that would be politically problematic. So that came out.
MH: Why did Denning and his GOP colleagues not insist on a work requirement for expansion enrollees, which Republicans have demanded in other states?
Bell: The more the work requirement has been discussed here, the less interested a majority of legislators were in it. That’s partly because it’s been struck down in court and also because they saw it as something potentially very difficult for the state and for healthcare providers to implement.
MH: Will the bill’s provisions for work referrals and a work readiness questionnaire create obstacles to people enrolling in Medicaid?
Bell: That remains to be seen. We need to watch and make sure it’s not something that creates disincentives for people to get on the program.
MH: How do your members feel about the per-enrollee hospital surcharge, capped at $35 million, to pay for the expansion?
Bell: That wasn’t our first choice. But our members felt we’d be penny-wise and pound-foolish not to put up a little money to get substantial money back in return.
MH: What impact will the bill, if it passes, have on hospital closures?
Bell: We’ve never said Medicaid expansion is a panacea to closures. You try to find all the tools you can to help you solve that problem. One is for Congress to undo budget sequestration. Another is to look at new models for care in rural areas. But it’s clear that expansion will benefit all hospitals, particularly smaller rural facilities.
MH: The bipartisan deal also would establish a new state advisory committee to support rural hospitals in developing innovative delivery models. How would that work?
Bell: That will be an action group working with Kansas’ congressional delegation to make it possible for some communities to move to a different model of care with potentially less inpatient care and more primary care to serve those communities better.
MH: Did action on Medicaid expansion in the surrounding states influence this deal?
Bell: I think passage of the Medicaid expansion ballot initiatives in Nebraska and other states in 2018 played a role in moving this forward in Kansas. One thing in the back of people’s minds is that Missouri and Oklahoma are looking at expansion ballot initiatives. They’re thinking if we don’t do this, we could end up surrounded by expansion states. If you are trying to recruit someone to a hospital in western Kansas and they know that across the border in Colorado there are going to be substantially more people who have health coverage, that’s not a competitive advantage for Kansas.
MH: Is Medicaid expansion a done deal in Kansas, or are there still doubts it will pass?
Bell: With the majority of senators co-sponsoring the proposal, we are extremely hopeful. But we’ve been working on this for so long, we don’t want to take anything for granted. There are a thousand things in any legislative session that can go wrong.
MH: Should Kansans be worried that the Medicaid expansion and the whole ACA could be erased by the legal challenge in Texas, which the Kansas attorney general has joined?
Bell: I find it incredibly hard to believe we would do anything that undoes Medicaid expansion when almost three-fourths of U.S. senators are from expansion states that are happy with it. You can make the argument that this is even more of a reason to push forward and do expansion, because you could be grandfathered in if you’ve already done it.
MH: Do you see this agreement as your capstone career achievement at the KHA?
Bell: This is one of the things we’ve worked hardest on over the years, and it’s something I’ll look back on and say it was worthwhile.
MH: Gov. Kelly and Sen. Denning recognized your key role in the expansion deal by asking you to speak at the news conference where they announced it. How much credit do you take?
Bell: A little-known part of the agreement is if I agreed to retire, they would pass expansion.