A rift between Republican factions in the Kansas Legislature and pressure applied by Gov. Laura Kelly threaten a tenuous agreement to produce a Medicaid expansion plan this year and vote on the legislation in January.

Medicaid expansion supporters in the House are frustrated that Senate leadership intends to craft the legislation without them, using an interim panel exclusive to senators.

The moderate Republicans are concerned about caveats that could be attached to the plan, such as work requirements or a tiered fee structure, and a showdown looms with Kelly and Senate Majority Leader Jim Denning both insisting they will write the guidelines that go to the federal government for approval.

Those guidelines, known as waivers, provide the framework for expanding eligibility to KanCare, as Medicaid is known in Kansas, and any proposed restrictions on the estimated 130,000 low-income adults and children who would gain coverage.

Denning, R-Overland Park, said he outlined his objectives for Medicaid expansion in a meeting with three moderate Republicans from the House on the final day of the session. The House members and Denning came away with a different understanding of assurances made during their meeting.

"It now appears to me that the governor and the Democrats want to splinter the Republicans on Medicaid policy moving forward," Denning said. "Of course, I would prefer the moderates stay with the Republican caucus to work on such a big piece of legislation. Timing has been the only issue we do not agree on."

Kelly, a Democrat who made Medicaid expansion a top priority when she took office in January, expressed frustration with Denning's refusal to allow a vote on Medicaid expansion this year even though a majority of senators approved of legislation passed by the House. The plan was modeled on a bill that passed in 2017 but was vetoed by former Gov. Sam Brownback.

"I offered one compromise after another to get Medicaid expansion across the finish line this year," Kelly said, including her willingness to withhold veto power on health care policy she opposed.

Moderate Republicans in the House teamed with Democrats in the final days of the session in an attempt to force Denning's hand by refusing to approve a budget. Fearing punishment from leadership, the House Republicans abandoned their holdout after receiving assurances from Denning that he would put a Medicaid expansion package to a vote in January.

Denning and Senate President Susan Wagle, R-Wichita, met with Rep. Don Hineman, R-Dighton, Rep. John Eplee, R-Atchison, and Rep. Susan Concannon, R-Beloit, to discuss the terms.

"The Senate leadership has committed to running an expansion bill across the floor of the Senate in January," Hineman said after the meeting. "We have received assurances that that bill will not be crafted by a unilateral, small handful of senators but by an interim study committee."

Denning said he offered to have ongoing discussions with Hineman and Rep. Kathy Wolfe Moore, a Democrat from Kansas City. The task of crafting legislation in the coming months will be assigned to a panel of senators.

Eplee said Denning made assurances that the panel would include House members and Democrats.

"He shook my hand on that," Eplee said.

Eplee also said he would be surprised if the bill actually gets a vote in January as Denning has publicly promised.

"I tried to be a team player on this," Eplee said. "It's really affecting people in rural Kansas. We will see more hospitals close. And it's just unacceptable to me when we have the capacity to fix this."

After the meeting, Eplee said, "it became abundantly clear to me that it just wasn't going to happen."

Denning agreed, at Hineman's request, to talk to a larger group of House Republicans, but the second meeting never materialized.

Rep. Tom Cox, R-Shawnee, said Republicans who were holding out hope for Medicaid expansion had a "robust debate" about what to do next.

"Many of us, myself included, said we need a written promise of a bipartisan, bicameral interim committee, and we want to know who would be appointed to it," Cox said. "We were told we can't get that. So we said we at least want it in writing that the committee will be formed. Again nothing. At that point, I said, 'Then there is no deal.' A deal exists on paper, not differing accounts of a conversation in a private meeting."

House Republicans folded because they felt pressure from their districts to support the budget, Cox said. A day earlier, GOP leaders heightened tensions by proposing a $12 million cut to higher education. Those funds were restored in the final budget offer.

"Moderate Republicans did the right thing moving the budget along and closing down the session," Denning said, choosing "to govern rather than grandstand."

Denning said the Senate will produce a better Medicaid expansion product than the one the House approved this year. That plan was passed by lawmakers who engaged in parliamentary high jinks to insert Medicaid expansion into an unrelated bill, a process known as a "gut and go."

By moving a competing plan through a Senate panel, the separate pieces of legislation would qualify for a conference committee with the House next year. Two Republicans and a Democrat from both chambers would then negotiate a compromise.

"They have minimal positions to negotiate, will stipulate to that, but that is what happens when you gut and go," Denning said. "In other words, you want it bad, you get it bad."

The priorities outlined by Denning include submitting waivers to establish a reinsurance system, as well as tiered rewards for patients who have annual wellness exams, premium assistance payments for qualified patients who find insurance outside of the Medicaid system, and guardrails for mental health services.

"Denning’s priorities are a little puzzling because many of them are already addressed in the 2019 House-passed expansion legislation or are unrelated to expansion," said April Holman, executive director of the Alliance for a Healthy Kansas, which advocates for Medicaid expansion.

"There is very little in this list of priorities that needs further exploration," Holman said, "which makes the Senate leadership’s yearlong delay all the more painful for the thousands of Kansans who need health care coverage."

The waiver submissions are an administrative function separate from the Legislature, but the governor's willingness to agree to terms could be a factor in the Senate leadership's willingness to move forward with a vote on the Medicaid expansion plan. Kelly said Denning can write any waivers he wants, but hers will be the ones that matter.

Senate leadership refused to allow a vote this year, the governor said, because they only cared about scoring a political victory.

"They never wanted to negotiate," Kelly said. "They never even tried."