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Medicaid Expansion Uncertain In Missouri

Elana Gordon

Last year’s Supreme Court ruling left a key part of the federal health law up to states to decide: whether to expand Medicaid. About half of states have said they’ll go along with an expansion. The rest are undecided or opposed. Leaders in Missouri are still divided on what to do. Missouri’s Governor supports an expansion but he faced one of his toughest crowds yet, when meeting with Senate leadership this week.

Governor Nixon, a Democrat, has made it really clear ever since he was reelected that he wants Missouri to expand Medicaid.

“It is the smart thing to do, and it is the right thing to do,” Nixon first said last November at Truman Medical Centers in Kansas City.

Nixon has since made more than 30 stops around the state, reiterating that message. That happened as recently as last Thursday at St. Mary’s Hospital in Blue Springs, a day after meeting with House leadership about the issue. Nixon said a Medicaid expansion would be an economic boon for the state, reigning in lots of federal dollars to the health care sector. The move would also cover about a fourth of the state’s population that’s currently uninsured, or about a quarter million people.

Hundreds of thousands of working Missourians who are an injury or an illness away from medical bankruptcy,” Nixon told health and business leaders in Blue Springs. “That doesn’t help the bottom line of our health care system, that doesn’t help out workers do better work. It cost shifts tremendous amounts of costs to folks who do have insurance, and quite frankly, it makes a workforce that’s not fully healthy.”

Republican lawmakers especially worry about the cost of an expansion.

“I would question adding 300,000 people to our current existing Medicaid rolls is a smart thing to do,” said Republican Will Kraus, state senator whose Jackson County district includes Blue Springs.

Kraus doesn’t see much traction in the Republican controlled legislature for an expansion this year. Medicaid is the largest part of the state’s budget, making up about a third of it.

I think it’s always a bad idea to rush to get something done, especially when it’s so significant like this,” said Kraus. “And I know people are concerned we’re giving up fed dollars.  You know, I’m concerned and a lot of my colleagues are concerned about the long term impact on our overall state budget and how we’re going to pay for it.”

Credit The Missouri Senate
Leaders of the Missouri Senate recently issued the following statement, reiterating their opposition to a Medicaid expansion.

Kraus says there’s too much concern about the long term health care costs of an expansion – the state would have to kick in more dollars after a few years.

But there has been one Republican-led proposal that’s gained a bit of traction. Representative Jay Barnes, of Jefferson City, sponsored a bill that passed out of committee last week.  Barnes says his proposal is a lot different from a flat-out expansion. He describes it as a market based approach that brings in price competition.

What House Bill 700 would do is when a recipient signs up for Medicaid, they would receive a menu of essentially private health insurance plans they’d be able to choose from,” Barnes said. “And beside those plans, they would have price. And they would be told if they picked plan that saves taxpayers money, they would get to keep a portion of those savings.”

So instead of putting newly eligible people on a standard Medicaid plan, those people would select from private health insurance plans. There’d be incentives built in for them to choose the least expensive options.

But Stan Hudson, with the University of Missouri’s Center for Health Policy, questions whether that will work. For one, Barnes’ proposal doesn’t expand coverage to the income threshold that the Affordable Care Act requires in order for Missouri to get full federal funding. He also thinks a private health insurance model could actually be more expensive. That’s because it may make it harder for people to access health care that really need it.

The idea is that Medicaid clients don’t pay for their care, or if they do, they’re paying dollar copays, so they don’t really feel it, they’re insulated from the prices, and that exposing them to that would then make them make better health decisions. And what health literacy shows us is that in a lot of places, they don’t have the skills necessary to make those decisions,” said Hudson. “There’s other research that shows in Medicaid populations that shows if you even raise copays or raise expenses to like two or three dollars, that you lose people.”

Hudson says when people don’t get the care they need because of this, they often wind up with more costly care in the long term, such as through the emergency room.

Governor Nixon has said Barnes legislation is a good start. Nixon has now moved his persuasive efforts for an expansion to the Senate. On Tuesday, he met with Republican leaders for the first time. He is also in conversation with the U.S. Department of Health and Human Services about some elements of the Republican proposals.

But for any deal to happen, a lot more negotiating and persuading would have to take place in the little over a month left in Missouri’s legislative session.


This story is part of a reporting partnership that includes KCUR, NPR and Kaiser Health News. . . . 


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