This article first appeared in the St. Louis Beacon, Dec. 5, 2012 - For the Missouri Hospital Association, the key to getting legislators on board with a push to expand Medicaid is making a pitch about the move’s economic opportunity — and the practical consequences of inaction.
"It isn't the matter that 'we should expand Medicaid because it's the right thing to do, although that is certainly still a strong argument,'" said MHA spokesman Dave Dillion. "Not only could we accomplish that, but we could create an economic engine by doing that."
But state Sen. Rob Schaaf, for one, is unmoved so far by what he's heard from proponents of the expansion. That includes the association and their advocate in the Capitol, Gov. Jay Nixon, a Democrat.
In fact, Schaaf, a St. Joseph Republican and a physician, literally takes an opposite view to the push for the expansion.
"Gov. Nixon says that he thinks that expanding Medicaid is the right thing to do. I think it’s the wrong thing to do," he said. "The bottom line of it is — and my deepest feeling is — we don’t do a very good job of helping the people in Missouri who can’t really help themselves. And now what they want to do is give able-bodied Missourians free health care at the expense of everyone else.”
Schaaf is only one legislator out of the 197 who make up the Missouri General Assembly. But as a member of the GOP majority, he exemplifies the challenge of boosting Medicaid eligibility to 138 percent of the federal poverty level. GOP opposition to Medicaid expansion is as much philosophical — the wrong thing to do — as financial or political.
The association, Nixon and other supporters of expanding Medicaid see two things in their favor: Nixon contends that it would create thousands of jobs. And the other is pressure from hospitals and other medical providers who say they would suffer — such as rural hospitals — if Medicaid isn’t expanded.
Among other things, they cite a provision of the new health-care law that would phase down federal payments to hospitals to help cover their costs of uninsured patients.
But Schaaf — a longtime adversary to the hospital industry — sees things differently.
"This is how it always works," said Schaaf, who contends that large hospitals could absorb federal cuts. "The special interests that are going to reap hundreds of millions of dollars of benefits always advocate for this and always resist putting competition into their marketplace. And the government always protects their monopolies and oligopolies. And health-care costs don’t go down."
Watching other states
The Medicaid expansion is a key aspect of the Affordable Care Act, also known as "Obamacare." Under the ACA, the federal government would fund 100 percent of the expansion from 2014 to 2016. After that, Missouri would gradually pick up a share of the cost until it pays 10 percent of the expansion by 2020.
The reason there's debate is that the U.S. Supreme Court ruled earlier this year that Medicaid expansion is optional. It's up to individual states to decide whether they want to participate.
The proposal in question would expand Medicaid coverage for all Missourians with incomes up to 138 percent of the federal poverty level. Currently, most adult Missourians can make no more than 19 percent of the federal poverty level. Percentages are higher for children.
In Missouri, the expansion would add roughly 300,000 more people to the state rolls.
Last week, the Missouri Hospital Association and the Missouri Foundation for Health released a report about the expansion's economic impact. Those two groups told reporters that the expansion would create thousands of jobs, increase state and local tax revenue and lower the costs of private insurance premiums.
"Expansion of Medicaid in Missouri is projected to generate an additional 24,008 jobs in Missouri in 2014," the report stated. "In one year, this is more than the employment of Missouri’s 10 Fortune 500 companies in the state. It also is 12.8 percent of the total unemployment number in Missouri in 2011."
Those type of figures should give pause to Republicans who cite economic development as a top priority, said state Sen.-elect. Paul LeVota, D-Independence.
"When the Republicans see the dollars and cents of it — that it creates 24,000 new jobs in the first year alone – they’re going to accept it," said LeVota, a former House minority leader who battled with Republicans over the issue for years. "This legislature has been very active in giving tax credits and other incentives to create jobs. This is a different version of that, if they look at that way. And I think they’ll see that."
But dissident lawmakers are watching other states, where their Republican counterparts are continuing to resist. In some states, such as Florida, some Republicans are softening their opposition. In others, Republicans remain opposed.
"If 20, 25 or 30 states decide not to expand Medicaid," said Sen. John Lamping, R-Ladue, "then it would probably end up being a situation where the federal government would have to reopen the law and ... figure out how to change the law in a certain way that it ultimately gets to be implemented."
Ace-in-the-hole?
The push by the hospitals and Nixon reopened a debate over Medicaid going back to the last decade. The flashpoint came in 2005, when the GOP-controlled legislature and Gov. Matt Blunt approved steep cuts to the program, which provides health care to the poor and disabled. Subsquent efforts by both parties to expand eligbility have faltered over the years.
But the decision to cut Medicaid hasn't appeared to wind down Republican legislative majorities. Starting in January, Republicans will have super-majorities in both the House and Senate: Republicans will hold 24 out of 34 state Senate seats and — pending the result of an undecided race in southeast Missouri — at least 109 of the 163 seats in the Missouri House.
While Nixon told reporters that the "personnel" in the House and Senate changed since the 2005 Medicaid cuts, veterans of the old Medicaid fights do remain. In the Missouri Senate, 14 members of the Republican caucus voted in 2005 to make the cuts to Medicaid — a list that includes Schaaf, incoming Senate President Pro Tem Tom Dempsey, R-St. Charles, and incoming Senate Majority Leader Ron Richard, R-Joplin.
"Several of us who were there in 2005 and did the right thing by putting our state on a solid fiscal footing by cutting back on Medicaid would feel that they're just giving back that ground on that hard-fought victory," said Schaaf, who added he would prefer to focus on increasing eligbility for the blind, aged and disabled. "And several of us who turned down the attempts to increase Medicaid in the past years — like Insure Missouri — we would just be reversing our positions.”
But one potential difference between the current Medicaid push and past ones is that medical providers — such as hospitals — appear ready to lobby legislators aggressively.
Last week, for instance, Steve Lipstein, the president of BJC Health Care, accompanied Nixon in St. Louis. Lipstein leads the largest private employer in the state.
After Nixon’s remarks, Lipstein told reporters that BJC's "ability to sustain that employment in support of providing outstanding patient care is contingent upon the legislature approving the governor’s program for the expansion of Medicaid."
"If Missouri doesn't expand Medicaid, there are a couple of things that happen," Lipstein said. "Hundreds of thousands of low-income Missourians that could otherwise be eligible for health insurance don't have it. They continue to seek out medical care in the highest cost venues of medical care that we offer: the emergency room."
He and other expansion noted how payments to cover uninsured patients at hospitals are expected to go down in the next few years. That could hurt hospitals with lots of Medicaid patients — including those in rural areas overwhelmingly represented by Republicans.
At least one Democratic lawmaker put the consequences in much starker terms.
"I want you to think for a moment about a rural Republican legislator who represents a community that's got a little community or county hospital," said state Rep. Chris Kelly, a Columbia Democrat. "Boone County will lose $30 million if Medicaid expansion doesn’t occur."
The question, said Kelly, is whether Republicans are "going to slit the economic throats of their communities to stay ideologically pure."
Kelly asks Republicans "how does (opposition to the ACA) weigh against your own chamber of commerce or the president of your own hospital board coming to you saying 'if you persist in this opinion, we’re going to lose our hospital?' "
Dillon said Kelly's contention has some validity, although he added that his group has "been very guarded in saying that hospitals are going to go out of business."
"It is fair to say that many hospitals — especially rural hospitals — have a payer mix that would be more governmental payer than it would be commercial," Dillon said. "In the absence of being able to cost-shift to commercial payers, rural hospitals that have a more significant government-payer mix would be jeopardized more."
Tough crowd
Still, Republicans have indicated they see no reason to change course.
House Speaker Tim Jones, R-Eureka, and Dempsey, are decidedly cool to the idea. Dempsey told reporters late last month that his caucus likely would not go along with the expanion.
And Jones released a lengthy statement last Thursday saying he is "not going to be like so many other politicians and pass a program just for the immediate results while leaving someone else to pay for it down the road."
To bolster their cases, the two leaders and other Republicans often cite statewide passage of two propositions, in 2010 and November, that sought to restrict other elements of the ACA.
Both the House speaker and the president pro tem can effectively kill legislation by sending it to an unfavorable committee. Lamping predicted Medicaid expansion would have difficulty even getting out of a committee.
Still, Dillon said his group — and other provider organizations — remain optimistic.
"I think we’re going to be able to convince a lot of people who have been skeptical, because they’re looking at it from purely 'a providing health care to poor people is welfare" perspective,' " Dillon said. "This isn’t 2005. The federal government is going to pick up 100 percent the first three years and up to 90 percent throughout implementation. So, it isn't fighting the same battles that have been fought in the past. It's an entirely different game."
Beacon political reporter Jo Mannies contributed information to this story.
