Why haven't Kansas and Alabama — among other holdouts — expanded access to Medicaid?

Medicaid provides health care to some 80 million Americans living on low-incomes. But millions more fall into the so-called "coverage gap" where they make too much money for Medicaid but not enough to get their own insurance.

With Medicaid expansion, states and the federal government can cover those making up to 138 percent of the poverty level - about $20,000 a year for an individual.

The federal government pays for most of it through the Affordable Care Act, also known as Obamacare. Democratic-led states were quick to jump in since it became available in 2014 but Republican-led states were not.

More recently red states have joined in. But 10 still have not - mostly states where voters cannot put the issue on the ballot to decide themselves. The Mississippi Legislature is considering it now.

Here's a look at two states where Medicaid expansion faces stiff opposition: Alabama and Kansas.

It's Kansas Gov. Laura Kelly's sixth year campaigning for Medicaid expansion and facing Republican opposition. Now she's appealing directly to voters.

"If we do not get Medicaid expanded this session," she recently told reporters, "then I would hope that they make it the number one issue going into the November 2024 election and that they hold their representatives accountable."

Her office says the proposal would enable an estimated 150,000 more Kansans to enroll in the health care program.

That includes people like Marcillene Dover, a high school physics teacher from Wichita who was driven into advocacy by her own experience back in college. She had aged out of her childhood Medicaid and was among adult Kansans who have trouble qualifying again without the expansion.

"I was about a month or two into classes," she said. "And I started having weird symptoms like numbness, tingling in my legs."

She said that after two years of symptoms, a nonprofit paid for an MRI that showed she had multiple sclerosis. Now 30 years old, Dover said she might not be using a wheelchair today if the illness had been caught sooner.

"Having no ability to get diagnosis or get treatment meant having more physical disability that is permanent, that cannot be treated, that there is no cure for," she recently told lawmakers.

Despite polls finding a majority of Kansans support Medicaid expansion, Republicans who control the legislature have blocked it.

"(The governor) truly believes that the government should take care of everybody," House Speaker Dan Hawkins said in an interview at the state capitol in Topeka. "I don't. I believe we all have an individual responsibility."

He says Medicaid expansion is too expensive and would give some people "no reason to work."

Nearly 60% of those who'd be covered under Kelly's proposal do work at least 20 hours per week, according to an analysis by the Kansas Health Institute, which seeks to increase health options for Kansans.

To attract Republican support, Kelly has now included a work requirement. But Hawkins thinks it's still too weak.

A handful of Republicans do support Medicaid expansion, including Rep. Jesse Borjon, who thinks the policy is pro-family and pro-business.

"One of the No. 1 issues that I hear from my constituents is on Medicaid expansion," the Topeka Republican said, "And they can't understand why the legislature can't get it done."

With urging from Borjon and others, the House health committee recently held a hearing on the governor's proposal for the first time in years. But a day later, the heavily Republican committee defeated it in a voice vote.

While lawmakers still have the ability to push the legislation through this year, analysts say it's unlikely.

Every day, Dr. Brittney Anderson has to turn away new patients at her small, rural clinic in Demopolis, Alabama. "It's heartbreaking sometimes," she said. "I'm only one person. I can't squeeze more hours into the day."

Anderson treats about 1,700 people in her solo private practice. She said rural doctors are facing a crisis in the state because of uninsured and under-insured patients.

But if Alabama adopted Medicaid expansion at least 174,000 more people would be covered, according to KFF, the health policy research group.

An attempt to tackle the problem this year was buried deep within a bill about a very different subject. A casino gambling bill contained a provision allowing gaming profits to go to rural hospitals, which some advocates hoped would be a form of Medicaid expansion. But the casino proposal was gutted and the rural clinic funding went with it.

Medicaid expansion opponents say it's federal overreach.

"You're giving up a lot of your sovereignty as a state to set health policy," said Justin Bogie, senior director of fiscal policy at the Alabama Policy Institute, a research group that says it's committed to limited government.

"If you open up this federal subsidized program for hundreds of thousands of people, then it could actually hurt that labor participation rate, give them another reason not to go to work, to stay at home," Bogie said.

Research and supporters of Medicaid expansion say many in the coverage gap — more than 40% — do work, they just don't have insurance.

Bogie and groups like the Alabama Hospital Association say they want to close the coverage gap through a state-run plan that would use federal dollars to subsidize private health care. But that hasn't been put in place yet.

Federal Medicaid expansion is also a non-starter in the Republican-dominated state legislature because of its connection to Obamacare.

"Just the partisan nature of this is definitely a problem," said Regina Wagner, professor of political science at the University of Alabama. Wagner said that for years Republican legislators in the south promised to repeal Obamacare. But other red states have adopted the program under public pressure.

"A lot of rural voters are Republicans. And so your own constituents are being hit by this and you're not addressing it," Wagner said. "If the pressure gets high enough and and sentiment shifts, maybe that's going to be enough to push them."

Rose Conlon covers health care for KMUW and the Kansas News Service. Drew Hawkins covers health equity for the Gulf States Newsroom.

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