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On the Trail, an occasional column by St. Louis Public Radio political reporter Jason Rosenbaum, takes an analytical look at politics and policy across Missouri.

On the Trail: Nixon reflects on a failure to expand Missouri's Medicaid program

Missouri Gov. Jay Nixon takes questions from reporters in 2015.
File photo / Carolina Hidalgo
St. Louis Public Radio
Gov. Jay Nixon made expanding Medicaid a top priority when he first ran for governor. While he made some small steps, he was largely unsuccessful in achieving that goal.

After Gov. Jay Nixon placed his signature on legislationthat could expand Medicaid for Missourians who are disabled or elderly, I couldn’t help but think back to when the Democratic official visited Bob Pund’s apartment.

Nixon was a mere attorney general when he ventured into Pund’s residence back in 2007.Pund is paralyzed from the shoulders down and had been critical of major cuts made to Medicaid in 2005.As Nixon sat in Pund’s living room, the aspiring governor vowed to make reversing those reductions a priority of his eventual administration – even if he was faced with a Republican-controlled legislature.

“I’m not going to take any sort of criticism or yammering from anybody who voted to cut these people’s opportunities for their life,” said Nixon, responding to a question from a more youthful version of this bespectacled reporter. “Whether someone’s a Democrat or a Republican, I’m going to work to sensitize them to the reality of these issues and work with them to explain and draw down federal dollars and begin to get this state moving in a different direction.”

In some ways, Nixon may have made a little bit of headway on that pledge last week. The bill he signed gradually raises the amount of assets that a Missourian who is blind, disabled or elderly can have to qualify for Medicaid. And that may allow more people like Pund to get crucial Medicaid services, like in-home care.

But with only a few months left in his term, Nixon is almost certainly going to fall short on his bid to make more comprehensive expansions to Medicaid. That Republican legislature he promised to sensitize blocked a number of proposals – including a small expansion early in his termand larger one that was presented under the auspices of the Affordable Care Act. 

“They’re not federal dollars. They’re your dollars,” said Nixon, in response to a question about the failure to pass Medicaid expansion -- and what it would take to shift the momentum. 

“Bizarre analogy”

After pausing for a moment, Nixon ultimately said: “And you’ll think this is a bizarre analogy, Jason. But you have an odd twist sometimes on the news, so you can probably tolerate it.”  

Missouri Gov. Jay Nixon speaks in St. Louis on Thursday June 9. The governor appointed three new members to the University of Missouri Board of Curators on Wednesday.
Credit Bill Greenblatt I UPI
Missouri Gov. Jay Nixon speaks in St. Louis on Thursday June 9. Nixon signed a bill that could expand Medicaid to blind, disabled or elderly Missourians.

Nixon noted how the Missouri Highways and Transportation Commission recently backed two major bridge projects in Franklin and Pike Counties. And he wondered aloud about the lack of outcry from Republicans over those fairly popular projects. 

“A big part of the dollars that will ultimately pay for both of those projects are gas tax money paid for by Missourians that went to the federal government,” Nixon said. “I wish that we could be as equally non-political about drawing down monies to help human beings as we can to help 18-wheelers and people getting across rivers. OK? Ultimately, this stuff gets down into individual stuff. But from a perspective of the finances?

“Are we going to say ‘no, we want to have a decrepit bridge over the Missouri River that we can’t drive across because, oh my gosh, we might have to use some money that comes from Washington – even though we pay the very tax that gets that money back to build that bridge?’” Nixon added. “We would never say that.”

Nixon went onto say how, in his opinion, “...We’ve gotten so far off the rails that health care for folks that are working and have income levels at the low level are trying to move forward is somehow a political issue – I quite frankly have never really understood.”

“And so I don’t mean in any way, shape or form to demean people and say that a bridge is the same as health care for somebody who is sick,” said Nixon, adding that there's a significant federal match for highway funds. “It’s just a point where you could make a progress in areas like this, it gets people able in the future to come together to get that important policy provision done.

“That’s a long answer to a very simple question,” he added. “Once again: I don’t mean to say that it’s just about dollars. But it is if you don’t have them.”

Murky future

Still, Nixon's sentiments don't change the reality that members of the Missouri General Assembly aren't receptive to expanding Medicaid. 

Missouri Speaker of the House Todd Richardson speaks to state representatives last week in Jefferson City on May 13, 2016.
Credit File photo by Carolina Hidalgo | St. Louis Public Radio
Missouri Speaker of the House Todd Richardson speaks to state representatives in Jefferson City.

For instance: State Rep. Andrew Koenig was unmoved from his position after hearing a clip of Nixon's remarks. Like other Republican lawmakers, the Manchester Republican said he's concerned about the long-term costs of expanding the program.

“With the transportation funds, what you have is sometimes one-time money or increased money,” said Koenig, one of two GOP candidates for a state Senate seat. “But with Medicaid, what you have is a failing program. People have poor access and what we need is to reform that program so it works better and we get better health care outcomes.”  

"You have poor outcomes and poor access," he added. "And why would you want to expand a program and potentially put taxpayers' money more at risk, even when the feds are paying part it? They're not going to pay it forever."

While likely Democratic gubernatorial nominee Chris Koster shares Nixon’s desire to expand Medicaid, it’s hard to see the needle moving much as long as the legislature remains in Republican hands.

As noted a few weeks ago, it’s not like the legislative path is getting much easier: When Nixon took office, there were far more Democrats who supported Medicaid expansion in the General Assembly. Those numbers have dwindled substantially – and its unlikely Democrats will make significant House or Senate gains later this year.

“I have a belief, and I think we have a caucus that has a belief, that we shouldn’t be talking about putting more people on a system that nobody thinks works very well today,” said House Speaker Todd Richardson, R-Poplar Bluff, last year. “And our first and primary mission ought to be to try to get Medicaid in a place that’s better than it is today.”

For his part though, Nixon said he hoped that the passage of the aforementioned asset bill represented a paradigm shift. 

"I just hope that this is the moment that people look back to in which they say that the politics of that issue subsided," Nixon said. "I think we have a responsibility. It's incumbent upon us once they change the framework... of how we draw those [federal dollars] back. And I think things like this will be a solid step forward to get that policy piece done."

"A long time coming"

In the process of writing this story, I reached out to Pund to get his thoughts on struggle to change Medicaid over the past few years – and about the bill that Nixon signed into law last week.

While emphasizing that “there are many more additional ways still to be done to improve the Medicaid program for people with disabilities,” Pund applauded the change in the asset limit, adding “...It's been a long time coming because $1,000 in 1967 would be more than $7,100 now.” The bill, which was sponsored by Rep. Kevin Engler, R-Farmington, passed with strong support of both parties.

“Most people do not think about Medicaid until they are forced into it,” Pund said. “Often, even people who have private insurance use up their private insurance and find that it does not cover the things you need even if you are able to afford the premiums after an injury or illness. In my situation for example, I had private insurance but it didn't cover the basic needs that I had every day that Medicaid does cover.”

Pund said he needs personal-care attendants in order to eat, wash or get out of bed. He also said, typically, private insurance only pays for one wheelchair in a lifetime.

“It is a real shock to find after you get out of the hospital that you have to get rid of everything of value just in order to survive which is a real insult to injury,” Pund said. “The Medicaid eligibility questionnaire is pretty humiliating to fill out and makes you feel like a completely unwanted burden on society. The form implies that you need to become a pauper and must give up all your possessions. They ask about furniture, jewelry...and burial plots.”

He went onto say that this “small change in rules will encourage savings and independence and give even larger symbolic changes where you don't feel like you are required to give everything up just to have insurance that allows you to survive.”

“If you need to get rid of your assets to survive, you will. I expect that the rule change will benefit the whole state and its finances by empowering people with disabilities and seniors over the long run,” Pund said. “You will be allowed to honestly report what you have and save a little bit of money just like every other person. You are more likely to be able to keep a car or van so that you can live a more productive life and contribute to the community by volunteering and working which is also good for your health.”

On the Trail, a weekly column, weaves together some of the intriguing threads from the world of Missouri politics. 

Follow Jason on Twitter: @jrosenbaum

Jason is the politics correspondent for St. Louis Public Radio.