Hospitals are pushing for Medicaid expansion in Missouri. Physicians say it’s crucial. And yet, lawmakers in favor of expansion have been unable to offer a proposal that the legislature’s Republican majority will accept.
In Gov. Jay Nixon’s latest pitch for Medicaid expansion, he outlined a number of caveats to appease conservatives. Nixon's proposal calls for people wanting to apply for Medicaid coverage to be working or actively looking for work to qualify for the lowest rates. Also, enrollees who call for ambulances under "non-emergent" circumstances could be penalized. Nixon also recommended offering incentives for healthy lifestyle choices, such as quitting smoking or losing weight.
“If that is the thing that gets a bill to the governor, then I think we should do that,” said Missouri Hospital Association spokesman Dave Dillon.
Dillon said he thinks the tone of the debate is starting to “rachet up” among the lawmakers who have opposed expansion.
“We’re hearing voices from the countryside of Missouri saying we can’t afford to have additional hospitals close,” said Dillon. “We’re all paying for it and it just doesn’t make sense to operate this way.”
Based on comments from lawmakers, Nixon’s proposal appears unlikely to pass in the General Assembly as St. Louis Public radio’s Marshall Griffin reported.
But even if a work-requirement bill is written and passed, it’s unlikely to fly when it’s sent to the U.S. Department of Health and Human Services, which has to approve Missouri’s expansion law before releasing federal funds to pay for it. (Those payments would be phased down over the years, to about 90% of coverage costs by 2020.)
“A work requirement’s not going to get through the federal government, and it shouldn’t, frankly. It’s counter-productive,” said Ed Weisbart, of Physicians for a National Health Program. “They just want to appear like they’re trying to do something.”
The federal government has approved alternate expansion plans, called waivers, from other states, but work requirements are generally not accepted. Federal officials denied a proposal similar to Nixon's from Utah in January, but the Obama administration pledged to revisit the issue.
“It really will be up to the federal government to determine if that falls within the options they’ll consider for a waiver. It’s better for us to be negotiating with them at this point," Dillon said.
Dr. Heidi Miller, who sees patients at Family Care Health Centers in St. Louis, said it would be pointless to add a work requirement, because most people who would benefit from the proposal are already working or have a family member who does.
“There could be a lot of bureaucratic effort and resources towards ensuring that people are working or trying to work, when in fact the majority already do,” Miller said.
Miller said many of her patients who are uninsured are working lower-wage jobs that are physically taxing. She lists patients who are house cleaners, airport shuttle bus drivers and a restaurant server with severe lower back pain — all who cannot afford the high price of specialty medical care.
“Carrying a heavy tray puts extra weight on the spine. He [the server] is really, really suffering, and he needs Medicaid in order to keep working,” Miller said. “Patients with health problems and without health insurance often can’t work because of their untreated medical problems.”
Missouri is one of 21 states that have not extended Medicaid eligibility to people who earn up to 138 percent of the federal poverty line, or about $33,500 for a family of four. Missouri’s current Medicaid eligibility sits at 18 percent of federal poverty for adults who have children.