Medicaid expansion remains a priority for Gov. Jay Nixon as Missouri lawmakers open their annual legislative session this week. Yet the prospects of that occurring appear slim.
Like last year, Missouri's Democratic governor and Republican legislative leaders are entering the session with a wide rhetorical and ideological gap on the question of whether Missouri should expand Medicaid eligibility to thousands of lower-income adults.
Republican lawmakers, who have instead called for Medicaid "reform," may even have trouble agreeing on what that should entail — raising the potential that no Medicaid legislation gets passed during the session that runs from Wednesday through May 16.
Missouri's Medicaid program currently covers more than 850,000 people.
Nixon's administration estimates an additional 300,000 — many of them uninsured — could eventually be added to the program if Missouri takes advantage of a federal health care law that pays extra money to states that raise adult Medicaid eligibility. Missouri would have to cover adults earning up to 138 percent of the poverty level, an annual income of about $32,500 for a family of four. The state currently cuts off eligibility at less than $4,500 annually for that same family.
Twenty-five other states already have expanded Medicaid eligibility and will be getting the bonus payments this year.
Nixon lists a Medicaid expansion among his top priorities for the legislative session.
"Let's resolve to pass a bill that brings our tax dollars home to strengthen and reform Medicaid," Nixon said last week.
But Medicaid expansion didn't even make the list of more than a dozen priorities that House Speaker Tim Jones outlined in an interview last week. Jones, R-Eureka, called the federal health care law a "disaster."
"The governor's really on the wrong side of history continuing to beat the dead horse of Obamacare and Medicaid expansion in our state," Jones said.
Jones and many other Republican lawmakers have suggested that Missouri should first "reform" its Medicaid program before expanding eligibility.
The House and Senate each created special committees last year to study potential Medicaid changes. The House committee hasn't issued a report. The Senate committee specifically rejected a Democratic recommendation for a Medicaid expansion and instead suggested that a "transformation of the entire Medicaid program must occur" first.
The Senate panel's top recommendation is to use managed-care insurance policies for all parents and children in Medicaid, something now in place in fewer than half of Missouri's counties. The report estimates that could shave about 3 percent off Medicaid's costs, or $38 million annually in federal and state funds.
The House committee also looked at proposals to adopt managed-care plans statewide.
Both the House and Senate committees discussed potential incentives for Medicaid patients to seek preventative care and avoid unnecessary emergency room visits while requiring them to meet co-payments or insurance deductibles through state-funded health savings accounts.
Page 2 of 2 - "There's no way we can talk about expansion without being efficient with what we have," said Sen. Gary Romine, R-Farmington, who led the Senate panel. "Most of my colleagues do not want to put more money into a system that's inefficient or ineffective."
But even that statement lacks consensus among Republicans.
Sen. Rob Schaaf, a Republican physician from St. Joseph, refused to sign the Senate committee report because of the managed care recommendation. Schaaf, who likely would filibuster a Medicaid expansion, asserts the current program is "really not that inefficient."
"I don't believe that managed care actually saves the state money," Schaaf said. "What it does is it enriches managed care companies and rations the care to the people who need it."
Legislation authorizing financial incentives or penalties for Medicaid recipients based on their health care choices likely would require special approval from federal Medicaid officials, said Rep. Jay Barnes, R-Jefferson City, who led the House Medicaid panel. He said President Barack Obama's administration is unlikely to approve Missouri's Medicaid changes without increasing eligibility.
"In order to be that laboratory of democracy — to show the entire country the way Medicaid ought to work — we're going to have to do some things we normally otherwise wouldn't do," he said.
It's not clear whether a Republican bill revamping the Medicaid program, without expanding eligibility, could make it past minority-party Senate Democrats who are adamant about covering more people.
Sen. Paul LeVota, D-Independence, who sponsored an unsuccessful Medicaid expansion bill last year, said legislation containing only Medicaid "reforms" would be "very short-sighted." He doubts Republicans would follow through by expanding eligibility after first changing the program.
"I think that's an excuse," LeVota said. "I think they just don't want to do anything."