GUEST COLUMN, Vance Ginn, Kansas Policy Institute
The debate over Medicaid in Kansas should start with a basic question: What should a safety net accomplish?
The goal should not be getting more people onto Medicaid or keeping them there. It should be protecting people who truly need assistance while creating better pathways for those who can work to earn more, obtain private health coverage, and become truly independent.
A new Paragon Health Institute analysis shows why this distinction matters. It estimates that 9.2 million people, or 46 percent of Affordable Care Act (ACA) Medicaid expansion enrollees, may not have met eligibility requirements in 2024.
That does not mean 46 percent committed fraud. Improper enrollment can result from outdated income information, government mistakes, incorrect classifications, or other eligibility problems.
But the result is the same for taxpayers: scarce resources are spent on people who may not qualify instead of being focused on those most in need.
The incentives contribute to the problem.
Under the ACA, Washington pays 90 percent of Medicaid costs for the expansion population, a much larger federal share than for traditional Medicaid. States determine eligibility while federal taxpayers pay almost the entire expansion bill.
Paragon estimates improper expansion enrollment cost federal taxpayers $32.9 billion in 2024. I recently discussed these incentives on my Let People Prosper Show podcast called This Week’s Economy, and in Medicaid Fraud: Following the Money.
Kansas provides another reason why accurate eligibility matters.
Through direct certification, information from programs including the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid can help determine whether students qualify for free school meals. The Kansas Legislative Division of Post Audit found that about 80 percent of qualifying students in 2023-24 were directly certified. Eligibility for the federal free lunch program is how the state determines funding for at-risk students.
Sharing accurate information can reduce paperwork. But inaccurate eligibility information can also spread from one government program to another. Verification matters.
The larger problem is dependency.
For work-capable, working-age adults, Medicaid should generally be temporary assistance, not a permanent destination. A better measure of success is whether people move into work, earn higher wages, and eventually obtain coverage they control themselves.
That fits the approach I have advocated through Empower Patients. Health policy should give individuals more control over health-care dollars and decisions rather than continually expanding government programs. More competition, transparent prices, portable coverage, and patient-controlled accounts can provide pathways away from dependence on Medicaid.
Federalism matters, too. Block-granting Medicaid to states could give states more flexibility while making them more responsible for how limited resources are used. That would change today’s incentive to chase federal matching dollars and give states greater reason to focus assistance on those most in need.
And Washington cannot finance everything forever.
As I recently wrote, states should prepare for a future in which federal dollars are less plentiful. With federal debt and deficits on an unsustainable path, assuming Washington will permanently finance 90 percent of Medicaid expansion is a substantial long-term risk.
The better question for Kansas is therefore not simply how many people Medicaid can cover. It is whether scarce resources reach those who truly qualify, whether taxpayers are protected, and whether people who can work have a clear path toward independence.
A safety net should help protect those who need it most while helping everyone else build a life beyond it.
