Topeka ? TOPEKA — Gov. Sam Brownback spent 2012 stiff-arming Obamacare, but received federal permission to turn over the Kansas Medicaid program to private companies.

That kind of maneuvering will likely continue in 2013 as more of the Affordable Care Act, commonly referred to as Obamacare, becomes a reality, the new Medicaid system, called KanCare, takes effect this week, and a major decision awaits on whether to expand Medicaid coverage to tens of thousands of Kansans.

“That, to me, is the big outstanding issue,” said Sheldon Weisgrau, director of the Health Reform Resource Project, which is funded by five Kansas health foundations. Whether Medicaid is expanded “will directly impact a number of people, how they access services, how many people will get sick and die in the state,” Weisgrau said.

At issue is whether Kansas should increase the income eligibility for Medicaid. Expanding Medicaid was a major provision of the Affordable Care Act aimed at getting more people under a health plan.

And while the U.S. Supreme Court ruled the ACA constitutional, the decision allowed states to decide whether to participate in the expansion. Several states, led by Democratic governors, have said they will expand, while several other states, led by Republican governors, have rejected the idea.

Currently, Medicaid in Kansas provides health care coverage to about 380,000 people, with the largest portion of them — about 230,000 — being children. The rest are mostly lower-income, pregnant women, people with disabilities and the elderly. The $2.8 billion program is funded with federal and state dollars.

Medicaid in Kansas doesn’t cover low-income adults who don’t have children. And a nondisabled adult with children is eligible only if his or her income is below 32 percent of the poverty level, which is approximately $5,000 per year. That is about the most difficult eligibility level in the country.

But starting in 2014, the ACA creates an eligibility level of 138 percent of the federal poverty level, which currently stands at $15,415 per year for an individual and $26,344 per year for a family of three.

Estimates indicate that Kansas’ Medicaid enrollment would increase by 135,000 people under the ACA expansion. In addition, health care experts say many more children would gain coverage as their parents sign up. Estimates show that about 70 percent of Kansas children currently without health insurance actually are eligible for Medicaid but are not enrolled.

If Kansas opts for the expansion, the federal government would pay for 100 percent of the additional cost for three years starting in 2014. Then the federal share would drop to 90 percent by 2020.

Several Republican governors have dismissed the expansion out of hand, but Brownback, also a Republican and ardent critic of the ACA, has said he wants to study the issue. He has expressed doubts that the federal government could afford the expansion in future years because of budget problems.

Weisgrau said policymakers should focus on what the law says now because future appropriations for anything done by the federal or state government are never guaranteed.

And while U.S. Census Bureau figures show Kansas’ uninsured population is below the national average, the state figure is going against the national trend.

The national uninsured rate decreased from 16.3 percent, or 49.9 million people in 2010 to 15.7 percent, or 48.6 million, in 2011, which was the biggest percentage drop since 1999.

But the uninsured rate in Kansas increased from 12.8 percent, or 350,000 people, to 13.1 percent, or 365,000.

Weisgrau said he is encouraged that Brownback is taking his time to study the Medicaid expansion issue, but he doesn’t believe the governor will opt in, given his other decisions related to the ACA.

In November, Brownback refused to partner with the federal government in setting up a health insurance exchange, touted as a one-stop place for people to compare and purchase health insurance.

“Kansans feel Obamacare is an overreach by Washington and have rejected the state’s participation in the federal program,” Brownback said.

Critics said Brownback’s decision cost the state an opportunity to set up the exchange in a way tailored to the needs of Kansans.

Brownback’s decision was no surprise. A year earlier, he rejected a $31.5 million federal grant to develop the exchange.

Supporters applauded the federal rebuff, but critics said Brownback was placating tea party Republicans.

Just weeks after bowing out of participating in the exchange, the Brownback administration received the go-ahead from federal officials to implement the state’s new Medicaid system, known as KanCare, on Jan. 1.

Under KanCare, nearly 400,000 Kansans will have their health care administered by for-profit managed care companies.

Brownback vowed that the new system will provide better health care more efficiently — ironically the same goals of the ACA. But the proposal has its detractors, such as the AARP and several other organizations that had asked for delays in implementation, saying that Brownback’s timeline was too aggressive.

In recent days, legislators who backed KanCare said they would file legislation aimed at allowing more legislative oversight over the Medicaid overhaul. That proposal will be debated next month as the 2013 session gets under way on Jan. 14.