This article first appeared in the St. Louis Beacon: State Sen. John Lamping emphasized on Monday that the Missouri Senate wouldn’t pass any Medicaid expansion in 2013, preferring instead to look to next year to resolve the issue.
And the Ladue Republican's assessment didn’t change after Gov. Jay Nixon spoke with the Senate Majority Caucus on Tuesday, a meeting roughly a week after he met with House Republicans.
“It was the first time he presented to us, but if you watch any of his videos for expansion or any of his talking points, he didn’t deviate much from that,” Lamping said in an interview with the Beacon. “We weren’t convinced by his arguments before. And so we’re clearly not convinced by his arguments now. I think he left there knowing that we’re not going to do this.”
Nixon has been barnstorming the state trying to build support for expanding eligibility for Medicaid to 138 percent of the federal poverty level. (That is about $26,000 a year for a family of three.) He argues that move would spur economic development and save hospitals from the worst consequences of fewer federal dollars. Nixon had some kind words about legislation from state Rep. Jay Barnes, R-Jefferson City, that would substantially change how the program operates.
The governor met with reporters after Tuesday's meeting. According to audio from St. Louis Public Radio, Nixon said he had a “substantive, thoughtful discussion” with members of the 24-member Republican caucus. He also said that he would talk with Health and Human Services director Kathleen Sebelius about issues related to the expansion.
“I am encouraged that the members of the House and the Senate are spending real, significant time looking at it,” Nixon said. “Like my meeting with the House majority caucus last week, today was an opportunity to discuss ways to strengthen Missouri’s Medicaid program the Missouri way.
“All in all, it was a good, solid, open discussion and I appreciate the senators’ time,” he added.
In a statement, Nixon said he had "a positive and productive conversation this afternoon" with Sebelius "about strengthening and reforming Medicaid."
"It is clear that moving forward and strengthening Medicaid will give us the flexibility we need to give Missourians the health system they deserve: one that protects taxpayers, rewards work, promotes personal responsibility and brings the tax dollars they send to Washington back here to Missouri,” Nixon said.
But at the meeting, Lamping said that “seven, eight or nine of us kind of spoke up to say ‘hey, this is the problem we see. We think this is a problem we’d see over here.’
“I’m only in my third session, but when any idea is brought forward and there’s a wave of questions about all the different aspects of the idea, you know right then and there you’re going to have a tremendous amount of work to do just to get to the place where people can even start thinking about voting or not voting for something,” said Lamping, who then reiterated that the Senate would work in the off-season on the issue.
Lamping went on to say the governor should have met with the Senate sooner if he was serious about passing Medicaid expansion this year. Traditionally, it’s more difficult to pass legislation out of the Missouri Senate, since a few members can either slow down or kill legislation they don’t like.
“It’s important that he actually did meet with us this session. I think he would have been remiss to go the entire session and not meet with us,” Lamping said. “But we have not had a caucus meeting specific to this, other than at the very beginning where none of us is of the mind to take this up. So I was impressed by the depth and pushback. Again, it was not just one or two issues. It wasn’t just one or two senators. It was a significant percentage of the majority.”
Lamping concluded, “If that were my idea and I was thinking it was going to pass this year, I would come back to my office and say ‘we have a lot of work to do between now and next November if we’re going to have chance of getting this done.’”
Nixon though said senators “were very curious, very thoughtful, very respectful, very specific.” He also said they had “a lot of questions, a lot of answers and a lot of good back and forth.”
“Clearly as we sit, the significant amount of legislative action to date has been handled in the House side in the measure that moved out of committee last week. I did talk to them about that most probably being the opportunity here to get reforms this year,” Nixon said. “And I think that for a lot of reasons, the issue is (more) legislatively mature in the House. But you’re seeing solid realization about how it’s important to get this done and get this done this year. So in that sense, the message moved the knowledge base down the field.”
Schaaf as a roadblock?
Lamping wasn’t the only senator who appeared unconvinced by the Nixon’s pitch.
In a speech on the Senate floor, state Sen. Rob Schaaf, R-St. Joseph, said that unless the governor agrees, at a minimum, “to have true competition injected into the marketplace,” Medicaid expansion is effectively dead on arrival.
“And I have to say there is only one possible way – and only one way – that a Medicaid expansion could make any sense,” Schaaf said. “And that would be if we recognized the perverse nature of this payment system and put in place factors that would allow it to come down through market reforms.”
One of those things, Schaaf said, would be to eliminate the certificate of need program, which is used to approve expansions of health-care facilities or expensive equipment. Schaaf noted on the floor that the hospital industry balked to changes to the process in 2008, when it was paired with then-Gov. Matt Blunt’s Insure Missouri plan.
“All we asked for was some reforms to inject a little bit more competition into the system. And they rejected it, even though hospitals would have profited to the extent of $100 million a year. They said no,” Schaaf said. “So now, here we have a situation where the hospitals are set to benefit by $2 billion from the new health-care law if we do Medicaid expansion. And do you honestly think that we asked them to put market reforms – serious market reforms – to put competition in the health care?”
“Do you think that they’ll agree to that?” he added. “I think not.”
Asked about Schaaf’s speech, Dave Dillon, a spokesman for the Missouri Hospital Association, said that his organization would be cool to the idea of tying certificate of need to Medicaid expansion. He added expansion “isn’t about price transparency, it isn’t about certificate of need.”
“Connecting it to something like that, frankly, does a disservice to the community of people who are really in need of the insurance that it would provide,” Dillon said. “We have been very open-minded in discussions about reforming Medicaid. We have been willing to take on any partners and listen to what their interests were in putting together a program basically not only in the expanded portion but across the board in Medicaid to make it more effective.
“But those are not things that are necessarily linked to it that would make that program more effective,” he added.
In many respects, Schaaf may be a major obstacle to any type of Medicaid expansion.
Pressure from the hospital industry isn’t likely to sway him, especially since the hospital association actively opposed him when he was up for re-election to the House in 2008and for the Senate in 2010. Since he first ran for the state legislature in 2002, he’s won every election by comfortable margins.
If any Medicaid expansion effort does come to the floor, it could be difficult to pass if others join Schaaf in a filibuster. That’s because filibustering senators could indefinitely talk a bill to death.
And that doesn't even take into consideration whether 18 votes are there to pass the measure out of the chamber. Lamping said yesterday that the "vast majority of that 24 would stand strong against an expansion."
Dillon acknowledges that “because of the way the Senate works, one senator can have a tremendous amount of power in moving a bill through that body."
Still he is not entirely pessimistic.
“On the other hand, if you look at our efforts with our organization this year with our coalition partners, I don’t think a year ago anyone would have anticipated that we’d have 50 chambers of commerce endorsing the Medicaid expansion,” Dillon said. “And I think the dynamic is changing to some degree on this discussion because there are a lot of people who at the beginning of the discussion realized how incredibly powerful the interests in this were. It’s reshaped for many the Medicaid dialogue we’ve had.”
