OLATHE — Carolyn Thomas chose not to seek emergency care for a serious hip injury to avoid the burden of a staggering medical bill.

Her inability to walk eventually cost her a job with access to health insurance benefits, dropping the caregiver of her deceased son's four children into a precarious fight for survival. She eventually qualified for disability benefits under KanCare, the state's Medicaid program.

"I'm grateful to God that I did not lose my home," Thomas said. "It was a very harsh struggle."

Thomas said there was reason to be optimistic the 2020 Legislature and Gov. Laura Kelly would follow collaborative impulses to pass a bipartisan bill expanding Medicaid eligibility for 130,000 to 150,000 low-income Kansas adults and children who don't financially qualify for Medicaid or cannot afford private health insurance. State lawmakers have an opportunity to consider in January at least three options for deepening access to Medicaid, with the objective to become the 37th state to make use of Affordable Care Act provisions available since 2014.

"There are so many out here like me that wish they had it and fall through the cracks," said Thomas, a student at Johnson County Community College.

Medicaid expansion became a political football as conservative Republicans and Govs. Jeff Colyer and Sam Brownback blocked reform sought by a coalition of Democrats and moderate Republicans. In 2017, Brownback vetoed an expansion bill. The House passed another during the 2019 session, but Senate GOP leadership narrowly staved off a plan to force a vote on it. The complexion of the game changed with the election of Kelly, who made adoption of an expansion law her highest priority for 2020.

"We'll get it done," Kelly said. "The issue is, really, getting it done correctly."

Chuck Weber, executive director of the Kansas Catholic Conference, said a Kansas Supreme Court decision declaring Kansans had a constitutional right to abortion was so disturbing to the organization that it conditioned political support for expanding Medicaid on first gaining approval of a constitutional amendment rejecting abortion as a "natural right."

The principle benefit of expansion would be extension of primary and preventative care to individuals and families in the coverage gap, including about two-thirds who work. For those who qualify under an expanded model, there would be less medical debt and more continuity of coverage. The ACA makes the federal government responsible for 90% of the cost of expanding KanCare.

Expansion would funnel resources to all hospitals, which absorb millions of dollars annually in uncompensated care. About 30 rural hospitals in Kansas are considered financially vulnerable, and expansion would inject resources into those facilities. Expansion would have an economic-development influence on communities statewide, but the bulk of funding would go to urban hospitals.

"Expanding Medicaid is the right thing to do," said Eddie Herman, president of HaysMed. "Medicaid expansion is not a silver bullet. It is not going to fix everything that is wrong with rural health care."

Over the years, Kansas' red-state voters were captivated by arguments by ACA opponents who maintained Kansas couldn't afford its share of an unrestrained entitlement program. Brownback appealed to opponents of government growth and gained traction with warnings the federal government would pull the rug out from under states by abandoning promises to pay for a burgeoning Medicaid system. Others questioned why the state would agree to enroll able-bodied adults without children in KanCare.

"You know and I know there’s a recession coming," said Rep. Brenda Landwehr, a Wichita Republican opposed to changing Medicaid eligibility. "Will Kansas be able to sustain this program?"

During the waning days of the 2019 session, the Kansas Senate fell a single vote short of forcing action on the House-passed expansion bill endorsed by Kelly.

Senate Majority Leader Jim Denning, R-Overland Park, promised to help develop an alternative. That proposal, endorsed by a GOP-controlled interim committee of the Senate, contained ideas appealing to Democrats and Republicans. It would require Kansas officials to seek federal permission for ideas floated by other states and denied — a process that could take more than a year to complete.

It didn't feature a work mandate for able-bodied adults but would require people not employed 20 hours a week to be referred to jobs programs. Expanded KanCare participants would pay 5% of household income in premiums and could be locked out for six months if they fell behind in payments.

He recommended a $50 million increase in the state tobacco taxes to subsidize health insurance rates in the private market. The state's share of higher KanCare costs would be financed through a $63 million fee on insurance companies running KanCare and a $31 million surcharge on hospitals.

"We can’t put any more stress on the state general fund," Denning said.

Senate Minority Leader Anthony Hensley, D-Topeka, introduced an amended version of the bill approved by the House. Instead of a fixed $25 fee for participants in expanded Medicaid, Hensley would allow the state to grant hardship exemptions to a fee. Hensley also deleted a lockout provision that would block re-enrollment of anyone missing premium payments.

Lt. Gov. Lynn Rogers said the final Medicaid expansion strategy ought to be simple, effective and sustainable. It should be implemented Jan. 1, 2021, and draw upon experiences of other states.

"Every Kansan, no matter their ZIP code, deserves quality health care," said Rogers, who believes delay would have lethal consequences. "There will be people that won't be diagnosed with cancer. They'll be paying more for pharmacy bills. In essence, more people will die."