Advocates for Medicaid expansion released a new study Monday on the plight of low-income Kansans, angling to inject new data into policy discussion ahead of November elections.

The study by Harvard researchers, sponsored by REACH Healthcare Foundation and Commonwealth Fund, concludes indigent adults have worse access to health care in Kansas than other states because of the refusal to expand Medicaid eligibility under the Affordable Care Act.

Based on phone calls in November and December with 1,000 people ages 19-64, researchers also found that few recipients would be affected by proposed work requirements because they are either disabled or already employed.

Kansas is one of 17 states that hasn't expanded Medicaid. The study, which cost more than a half-million dollars, compared numbers with two states that have -- Indiana and Ohio.

"The work really has shown that Medicaid expansion has been effective in improving insurance coverage, access to care, people's self-reported health status, and I think really led to the sense that across the country Medicaid expansion has had an unequivocally positive effect," said Sara Collins, a vice president for Commonwealth Fund.

About 152,000 Kansans would gain health insurance if Kansas expanded the program, which provides coverage for disabled and low-income residents. Federal funds would pay for 90 percent of the cost.

Opponents to the idea, including Gov. Jeff Colyer, object to the burden Medicaid expansion would have on the strained state general fund. The Legislature this year passed a school finance bill that eventually will add more than $500 million per year in education spending, and the Kansas Supreme Court ruled the amount needs an upward adjustment for inflation.

"You cannot discuss Kansas Medicaid expansion in a vacuum the way this study does," said Kara Zeyer, the governor's spokeswoman. "Any increase in SGF spending has to be seen in the context of the additional school spending appropriated in Kansas. The current budgetary priorities of the state preclude the large increase in SGF spending necessitated by Medicaid expansion."

Other states, including Indiana and Ohio, have seen costs skyrocket after expansion, Zeyer said, because enrollment exceeds expectations. Additionally, President Donald Trump wants to repeal and replace the ACA, known as Obamacare, which potentially could leave states on the hook for a greater share of expanded coverage.

"Not one state that expanded Medicaid under the ACA has managed to keep its enrollment under or on target with its initial projections," Zeyer said. "Higher-than-expected enrollment and higher costs in these states leave fewer resources available for all other priorities -- including services for the most vulnerable, for education, for public safety and for transportation."

Legislators passed Medicaid expansion in 2017 but fell a handful of votes shy of overriding former Gov. Sam Brownback's veto. This year, enough moderate Republicans flipped their position to prevent attempts at expansion, avoiding the uncomfortable veto situation in an election year.

At the time, Colyer -- the architect of KanCare, as the Medicaid system is known in Kansas -- was campaigning against Kris Kobach, who won the Republican nomination for governor. Both opposed expansion, whereas state Sen. Laura Kelly, the Democratic nominee for governor, sees it as a benefit to the state's economy.

Benjamin Sommers, a physician and health economist at Harvard's Chan School of Public Health, and Brenda Sharpe, president and CEO of REACH, said the upcoming governor's race was a factor in the decision to talk to people here.

"Kansas is really at the tip of the ongoing debate as to what the role is of Medicaid expansion and what's at stake for low-income adults in the state," Sommers said.

Their survey focused on those whose income is below 138 percent of the federal poverty level -- $16,000 for an individual or $34,000 for a family of four. Sommers said he relies on a nonpartisan polling firm that uses random-digit telephone numbers, then asks callers if they meet the age and income criteria. The results are controlled for variables like age, race, party affiliation, gender and family status, he said.

Among those surveyed, 20 percent were uninsured and 77 percent favored expansion. Compared to the other two states, Kansans experience more frequent delays in receiving health care because they can't afford medical bills.

"We hear a lot of anecdotal evidence in stories presented locally by policymakers in Kansas, and part of that is there is just a dearth of Kansas-specific research and analysis, and we wanted to be sure we had something that was much more real-time for policymakers to consider as they continue to weigh that decision," Sharpe said.

Only 17 percent said they would be affected by work requirements the state wants to impose if it receives approval from federal administrators. Only 11 percent said they would seek employment if they were required to do so.

Sommers said KanCare already is burdened by limited resources, and enforcing a work requirement would make things worse. Zeyer said expansion would create "new entitlements" for "welfare recipients."