This article first appeared in the St. Louis Beacon: The Missouri House has passed a new state budget without Gov. Jay Nixon's sought-after Medicaid expansion, but that doesn't mean Republicans are dropping the issue entirely.
The House Government Oversight and Accountability Committee is slated to vote Wednesday on HB700, a bill proposed by state Rep. Jay Barnes, R-Jefferson City, to change the state's current Medicaid program dramatically.
But word already is circulating that Barnes' bill, even if it gets through the House, will have a tough time in the state Senate. Fellow Republicans and most Democrats oppose his plan.
Meanwhile, Nixon is continuing to take his pro-Medicaid expansion tour on the road. He was in Wentzville today; last week, the governor was in Kirkwood.
And on Wednesday, the governor plans to be back in the state Capitol to meet with the the House Republican caucus in what is expected to be another pitch to expand Medicaid, as sought by the federal Affordable Care Act.
The federal government would pick up all the additional costs for the first three years, and cover at least 90 percent thereafter.
So far, House Republicans haven't embraced that plan, instead looking for other alternatives. Which is where Barnes' proposal fits in.
The House oversight panel conducted a hearing last week on Barnes' bill, which would result in dropping some people -- including children -- currently on the rolls and then adding others.
Barnes chairs the House committee and told the Beacon in a recent interview that his bill constitutes “a plan to fundamentally transform Medicaid system into the most market-based system not just in the entire country, but in the entire history of the program.”
Barnes said, “We are attempting to inject price competition into a system that for 45 years has been sorely lacking price competition. So we’re empowering participants to make their own health-care decisions and to do so in a cost-conscious manner that will save taxpayer money.”
Among other things, Barnes’ bill would place income eligibility for the program at 100 percent of the federal poverty level. It would also reduce eligibility in other areas, including children's health care.
The proposed poverty-line for eligibility is five times the state's current limit (19 percent) for adult participation on Medicaid, but it's less than the 138 percent required under the federal Affordable Care Act to receive federal money.
“The areas in which we’re reducing eligibility are populations that are going to have access to robust subsidies in a federal health-insurance exchange,” Barnes said. “So for example, a family of two making about $20,000 a year will have to pay about $34 a month for health insurance. That’s a reasonable cost for somebody to pick up. It will empower them to pick their own plan.”
Barnes’ plan would provide state contracts to competing insurers and would give patients incentives to choose lower-costs plans.
“Study after study has shown people who have private health plans get better health results versus people who are on Medicaid,” Barnes said. “And some of those studies even show that’s true controlling for income. And so we give participants better care – and we do it in a way that’s much cheaper for Missouri taxpayers.”
The legislation is contingent on the federal government granting a waiver to Missouri, Barnes said. That's important, because one of the tradeoffs of getting the enhanced federal funding is for states to raise the eligibility level to 138 percent of the federal poverty level.
“This is an all or nothing proposition. Either the federal government allows red states to craft solutions that work for them or we don’t do it,” Barnes said. “The fiscal note is either zero – because the Obama administration refuses to back off its ideological stance on a one-size-fits-all Medicaid. Or it’s positive fiscally for over $1 billion over eight years.”
Bill's fate may depend on feds
Barnes' plan has sparked a mixed reaction among groups watching the Medicaid battle closely.
Joe Pierle, chief executive of the Missouri Primary Care Association -- which backs the Medicaid expansion -- said in a statement that Barnes’ bill “is the beginning of a process to bring much-needed stability and predictability to the state’s health-care system.”
Barnes' bill, he said, "begins to build the framework for a Missouri solution to leverage our federal tax dollars to expand access to affordable health coverage for the working poor.
"Transforming the system and providing affordable health coverage to the working poor are not mutually exclusive," he said. "Both can be done at the same time."
Joan Bray -- a former Missouri senator who is now the head of the Consumers Council -- said in an e-mail to supporters that Barnes' bill “would introduce a number of changes to the state's Medicaid program but will never be implemented because the bill expands eligibility only to 100 percent of the federal poverty level."
“Secretary Kathleen Sebelius of the Health and Human Services Department has made it clear that states will receive Medicaid reimbursement only if they provide service to people with incomes up to 138 percent of the federal poverty level – nothing less,” Bray said. “Without this, Missouri’s bill is meaningless.”
State House Speaker Tim Jones, R-Eureka, released a 1,217-word statement last Thursday that Barnes' bill "does provide a solid starting point from which we can work toward the kind of Medicaid system our state needs both today and for the years to come.
"Regardless of how we proceed, we will be dependent on the federal government to grant us a waiver that will empower our state to innovate and transform our Medicaid system," Jones said in his statement. "The way Medicaid expansion was structured by the White House gave states a take-it-or-leave-it ultimatum when it comes to the federal dollars that are available."
Jones told the press last week, according to a recording from Missourinet, that "we’ve got to work through this process; it’s a long legislative process."
It’s also unclear whether the House proposal will gain legislative traction. The Columbia Daily Tribune reported earlier this week that Senate President Pro Tem Tom Dempsey, R-St. Charles, said that Barnes’ bill would have a dim chance in the Missouri Senate. Passage in that chamber is key, since bills there can be held up by a handful of lawmakers.
For his part, Nixon was in Kirkwood last Tuesday to drum up support for expanding Medicaid to 138 percent of the federal poverty. After his address, he told reporters that he was heartened that Barnes’ bill was a start of a serious discussion on the issue.
It's “good that there’s movement forward in the House,” Nixon said. Barnes’ bill "will be a vehicle that can get this to the finish line. And that’s important. So I think it's solid progress that people are working together to move the bill forward.”
Nixon cites other states' compromise approaches
Asked about whether any proposal would have to expand Medicaid up to 138 percent of the federal poverty level, Nixon said, “138 percent is what the federal government says that it needs to have.”
“But there are lots of ways to get to 138,” Nixon said. “You could put some of these dollars through an exchange, for example, so folks would have a way to go on the marketplace. So the way Arkansas did it and the way some other states are doing it. So there’s lots of ways to get to 138 that aren’t necessarily just move Medicaid to 138.”
Nixon was referring to how the federal government gave the green light, so to speak, to Arkansas' plan to expand health-care coverage to low-income residents through insurance exchanges as opposed to the Medicaid program.
Jones' statement said, "Many states are looking to Arkansas to see what unfolds as they push for a system that would enroll those newly eligible for Medicaid into the same private insurance plans available to individuals and small businesses."
That doesn’t mean Nixon is totally enamored with the proposal. In early March, he told reporters that he didn’t feel cutting children or pregnant women from the program were steps in the right direction.
“Do I have some issues with some portions of the bill? Yeah,” Nixon said last week. “But are we willing to work together? Absolutely. Will we work together to get reform? Yes. But the movement, the long hearing the House committee yesterday, the likelihood of that bill coming out of committee soon is a positive step for health care reform and Medicaid expansion.”
Jones went on to say at that many states are coming up with alternatives to Medicaid, adding "we’re going to have to come up with the Missouri solution." That term -- which was also used to describe a 2011 compromise on dog breeding legislation -- was also brought up in Jones' lengthy statement.
"As the president has seen more and more states refuse to accept federal dollars with all of the inflexible federal requirements, red tape and strings attached, we have seen a greater willingness to allow state governments the flexibility necessary to transform Medicaid as they see fit," Jones' statement said. "Our transformation plans will go nowhere unless the federal government agrees to let us develop the Missouri solution for Missouri’s Medicaid system," he added.
Nixon's pitch carries emotional tinge
Since Nixon announced his support for expanding Medicaid shortly after he was re-elected, the governor has spent the past few months traveling across the state to bolster his case on the issue.
His latest scheduled stop was Tuesday in Wentzville. Last week, he was at the Kirkwood Community Center to make his pitch.
Before he spoke, Nixon was introduced by St. Louis Regional Chamber President Joe Reagan – whose group is one of numerous chambers of commerce backing an expanded Medicaid. Just as he had before, Nixon said that expanding Medicaid would be an economic boon to the state by creating thousands of health-care jobs.
He also warned that failure to expand Medicaid could hurt the state’s hospitals since their reimbursement for uncompensated care is expected to go down in the next few years. That's one reason the Missouri Hospital Association has come out strongly in favor of the proposal.
The tail end of the governor’s speech included an emotional plea: Expanding Medicaid is morally right for people who are working at the lower-end of the pay scale.
“There are hundreds of thousands of working Missourians who don’t have one of those cards,” said Nixon, referring to a health insurance card. “And you know? I bet a bunch of them are doing really hard jobs. Like after this last snow, getting out there at night, making sure the streets are ready for the next day. Not just city workers, I’m sure they’re covered. Or the county workers. But you and I both know there are private folks out there that are working jobs for $9, $10 or $11 an hour with no insurance.
“And when they got home, maybe they broke an ankle or twisted something someplace,” he added. “And they have no health insurance card even though they work just as hard as anybody else in this room. Working Missourians. People making $9, $10, $11, $12 an hour on their way up. This provides them with the basic dignity and strength that health care and preventative health care can provide.”