JEFFERSON CITY, Mo. — A year ago, Missouri had a Democrat governor who strongly supported expanding the state’s Medicaid program in line with the original intent of the Affordable Care Act but a Republican legislature that was foursquare against the idea.

Those political dynamics appear unchanged as the General Assembly prepares to convene Wednesday for this year’s session.

But Medicaid expansions advocates said they are hoping that the differing factions might find common ground and extend coverage to thousands of uninsured Missourians, especially after three legislative committees spent the summer and fall studying ways to improve the state-federal medical program for the poor.

As a result of the study sessions and public hearings, “we have a lot of members of the House and Senate who are much more informed about these issues,” said Sidney Watson, a professor at the Center for Health Law Studies at Saint Louis University. “So I do think we are moving forward. I don’t think we know what direction it is yet or where we will end up.”

Political strategists said much of the focus would be on the Senate, which includes stalwart opponents, such as Sen. Rob Schaaf, a St. Joseph Republican.

But even the most ardent expansion proponents say there is little hope for a plan that would simply expand the state’s current Medicaid program to individuals making up to 138 percent of the federal poverty level. Instead, they say, Republicans are more likely to accept an expansion similar to those in some other Republican-led states, which use federal Medicaid dollars to help people purchase private coverage.

The federal government has pledged to pay at least 90 percent of the costs in states that expand eligibility to that level.

On the House side, proponents such as Rep. Jay Barnes, a Jefferson City Republican, have talked of crafting the type of “market-based” solution that other states have crafted to draw down the federal Medicaid dollars. He has specifically noted the Indiana plan enacted under Republican Gov. Mitch Daniels.

Barnes chaired last year’s House Interim Committee on Medicaid Transformation. Gary Romine, a Farmington Republican, chaired a similar committee in the state Senate.

Medicaid expansion proponents in Kansas, including the hospital association, also are trying to gain Republican support for plans that would use federal Medicaid money to help the poor buy coverage from private insurance companies.

The basics
Missouri has participated in Medicaid since 1967. Its name for the program is MO HealthNet.
According to a legislative report, Missouri’s projected Medicaid budget for the current fiscal year is approximately $9 billion, which includes about $1.8 billion from state general revenue.

Missouri has about 6 million residents and MO HealthNet serves about 15 percent of them, or about 874,000 beneficiaries. Children account for more than 60 percent of those enrolled.

About 877,000 Missourians lack health insurance, according to the Missouri Medicaid Coalition, a group that backs Medicaid expansion. Increasing Medicaid eligibility to the level included in the Affordable Care Act would provide coverage for nearly a third of the state’s uninsured population, according to the coalition.

In a statement issued Dec. 31, Gov. Jay Nixon appealed to the General Assembly to craft a plan that would reform and expand MO HealthNet.

In part, he said, that would ensure that Missouri tax dollars don’t go to other states that have expanded Medicaid and therefore qualify for more federal aid.

He said that even in states with Republican governors, such as Iowa, and Republican legislatures, such as Arkansas, lawmakers have crafted compromises to secure the extra federal Medicaid dollars.

“So as we begin the New Year,” Nixon said, “let’s resolve to work together to make Missouri a healthier place to live and work.”

Legislative battle
Nixon’s comments came just two weeks after some state senators refused to sign the final report issued by one the off-session study committees.

The report included more than a dozen recommendations to improve Missouri Medicaid, such as expanding the use of managed care throughout the state.

Democrats on the committee, including Paul LeVota of Independence, filed their own minority report blasting the majority for not mentioning Medicaid expansion in the report.

“The committee’s report is not based on the actual testimony and information presented to the committee,” the Democrats said.

They said more than half the testimony to the committee addressed Medicaid expansion and that nearly half those who testified were in favor of expansion.

The minority members wrote that Sen. Gary Romine, the Farmington Republican who chaired the committee, had told them that expansion was outside the panel’s purview.

Schaaf, the St. Joseph Republican, also declined to sign the final report, saying in an accompanying letter that his signature “would give my tacit approval to all the recommendations, both good and bad.”

He said he strongly opposed expanding Medicaid managed care, saying he was unconvinced it saves money and that it could compromise care for the aged, blind and disabled.

Schaaf also has said he opposes opening Medicaid to able-bodied adults earning up to 138 percent of the federal poverty level when the cut off for disabled people is 85 percent.

“This is the unreasonable result of ObamaCare,” he wrote in a recent newspaper editorial.

The House committee has not issued a report.

In November, Barnes, its chairman, released a spreadsheet that he said was intended to spur committee discussion. He did not respond to requests for an interview to explain his figures.

But the minority members of the Senate committee characterized Barnes’ spreadsheet as the outline of a plan similar to “premium assistance” models approved or underway in Arkansas and Indiana, where the state draws down ACA-approved Medicaid dollars to assist people buying private insurance through the marketplaces.

Barnes estimated his plan would save the state $779.3 million in general revenue between 2014 and 2021.

Observations
LeVota, the Independence Democrat, and Rep. Noel Torpey, an Independence Republican, both said there seems to be little appetite in the General Assembly to simply expand Medicaid without also reforming it.

Torpey chaired a House committee that toured the state last summer collecting public input on Medicaid. The overwhelming sentiment expressed, he said, was that people didn’t want one without the other.

LeVota said he and his colleagues on the Senate Medicaid committee favor some of the reform proposals in the majority report.

As executive director of the Missouri Health Advocacy Alliance, Andrea Routh has been active in the coalition to expand Medicaid.

She predicted that much of the push in this year’s legislative session would be to have constituents speak to senators in favor of accessing the additional federal Medicaid money.

She said the feedback from some senators has been that they have not really heard from ordinary people about the issue.

Nonetheless, she said she was puzzled by the General Assembly’s failure to act on Medicaid expansion.

“It is a head shaker to me when we don’t get this done,” she said. “Other conservative states have done this. It’s not like Missouri would be an outlier.”

Stories in this package

→ Kansas hospitals leading new push for Medicaid expansion
→ Profiles of the coverage gap: Kathleen Christian
→ Single mom in KCMO seeks benefit of preventive care
→ KS Senate president says Medicaid expansion unlikely to gain approval this session