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Showdown over Medicaid expansion delayed so state budget can pass by deadline

This article first appeared in the St. Louis Beacon, May 7, 2009 - To get a budget passed by Friday's constitutional deadline, the Missouri Legislature has taken action that appears to put off until next week a final battle over warring efforts to expand access to health care.

But all sides are pessimistic, saying there's not much hope for Gov. Jay Nixon's plan that called for expanding state health care coverage to 35,000 Missouri adults at no cost to state taxpayers. The Missouri Hospital Association and several business groups backed that plan, which called for the hospitals to pay higher fees to the state, which would be used as matching money for more federal health-care dollars.

Instead, the Republican majority in the Missouri House appears to lean toward a version of Senate Bill 306 that would expand access to health care through the state's high-risk pool for people deemed "uninsurable'' because they have pre-existing conditions or disabilities.

However, Missouri hospitals are not as supportive of that approach because it doesn't resolve the problem they now have with low-income, uninsured people who show up in the emergency room needing care. Because of the state's Medicaid cuts in 2005, the hospitals now aren't compensated for much of that care.

To meet the budget-approval deadline, the Legislature has stripped out of House Bill 11 a provision that would have put Nixon's proposal in effect unless legislators passed SB306. Now, unless a form of SB306 passes before adjournment May 15, there will be no major changes in law regarding health-care coverage in Missouri.

The debate boils down to two House visions of the state's role in providing access to health care.

State Rep. John Diehl, R-Town and Country, said he and other Republicans object to Nixon's plan -- which Diehl dubbed "welfare" -- because they believe it could cost the state money in the future.

"We don't want to put future budgets and future taxpayers at risk,'' Diehl said.

But state Rep. Rachel Bringer, D-Palmyra, says the Republican plan would cost the state more now -- and do nothing for low-income workers, like a waitress in a local diner. Many of the people who would qualify for coverage under Nixon's plan, she said, would be "a tremendous number of working mothers'' in low-paying jobs at businesses that don't offer health insurance.

The GOP plan, she says, would increase the state's costs under its high-risk pool because the state uses general-revenue dollars to subsidize insurance premiums for people who can't otherwise get the coverage. The state also provides tax credits to insurance companies that equal the amount the insurers have paid for health coverage above the cost of the premiums.

State Rep. Chris Kelly, D-Columbia, agrees with Bringer's financial analysis. "This is a classic example of when ideology overwhelms facts,'' he said, referring to the GOP view.

But state Rep. Jason Smith, R-Salem, said it was the Democrats who had the wrong approach. "It looks like the people on the other side of the aisle are going to provide health insurance to those who are able-bodied working adults, but are low-income," Smith said. "And they don't care about the other people who have pre-existing conditions that cannot afford health insurance at all."

A spokesman for Nixon said the governor still believed his proposal was best, and noted that it had bipartisan support in the state Senate. "If there are alternatives that would accomplish the governor's goal of expanding access to health care, he's certainly going to look at them closely,'' the spokesman added.

Legislative showdown

Earlier this year, Nixon announced with much fanfare his agreement with the Missouri Hospital Association.

The House rejected Nixon's plan early on. But the state Senate set aside roughly $147 million for a health-care program encompassed in SB306. As originally worded, if that bill didn't pass, then the money would have gone to implement Nixon's Medicaid proposal.

But Diehl said House Republicans believed that the Senate would have blocked any version of SB306 in favor of Nixon's plan.

In the end, House lawmakers balked. To make the budget deadline, senators had to go along -- at least temporarily.

The final fight got testy, with House Speaker Pro Tem Bryan Pratt, R-Blue Springs, accusing one of Nixon's aides of enticing lawmakers with appointments in exchange for a favorable vote. The governor's office denies the allegations.

Senate President Pro Tem Charlie Shields, R-St. Joseph, says that SB306 is likely to be passed by the state House on Monday. That will set the stage for a conference committee, and another round of debate in each chamber on the final version.

"My hope is we'll move forward and we'll bring more Missourians into coverage," said Shields.

But Senate Minority Leader Victor Callahan, D-Independence, wants to make sure the final program is effective at helping the working poor.

"I want this patience and our maturity in this body to be rewarded," he said.

Jason is the politics correspondent for St. Louis Public Radio.
Jo Mannies has been covering Missouri politics and government for almost four decades, much of that time as a reporter and columnist at the St. Louis Post-Dispatch. She was the first woman to cover St. Louis City Hall, was the newspaper’s second woman sportswriter in its history, and spent four years in the Post-Dispatch Washington Bureau. She joined the St. Louis Beacon in 2009. She has won several local, regional and national awards, and has covered every president since Jimmy Carter. She scared fellow first-graders in the late 1950s when she showed them how close Alaska was to Russia and met Richard M. Nixon when she was in high school. She graduated from Valparaiso University in northwest Indiana, and was the daughter of a high school basketball coach. She is married and has two grown children, both lawyers. She’s a history and movie buff, cultivates a massive flower garden, and bakes banana bread regularly for her colleagues.

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