The Joplin Globe, Joplin, MO

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March 28, 2013

Missouri House advances budget; Medicaid expansion not included

JEFFERSON CITY, Mo. — Missouri Republicans voted five times this week against a Democratic proposal that would accept nearly $1 billion in federal funds to expand the state’s Medicaid rolls.

The votes came as the House of Representatives debated its $24.8 billion budget for the fiscal year that starts July 1. The set of budget bills passed the House on Thursday with support from the Joplin area’s delegation. The plan includes modest increases in education funding but does not accept federal funds to expand Medicaid, as requested in Gov. Jay Nixon’s budget.

Instead of considering the Democratic proposal, Republicans are working on their own plan that they hope would “transform” the Medicaid program, not expand it. On Monday, the House Government Oversight and Accountability Committee met to consider a plan by Rep. Jay Barnes, R-Jefferson City. Barnes’ proposal would allow individuals with income levels at the federal poverty level to use the program, while seeking other reforms in an effort to cut back costs.

The plan, however, conflicts with the federal Affordable Care Act, which calls for income eligibility to be set at 138 percent of the federal poverty level, just over $32,000 for a family of four. Barnes’ proposal would require several waivers, including one that would allow the state to receive the funds, while nonetheless not complying with the federal law.

The federal health care law provides for nearly $5.7 billion over the next three years for Missouri to expand the state’s Medicaid rolls, if the state chooses to comply with the law. The federal government says it will fund the program in full for three years, before its share would gradually decrease to 90 percent by 2020.

Rep. Tom Flanigan, R-Carthage, vice chairman of the House Budget Committee, said Republicans have been abundantly clear about their opposition to the proposal from Nixon and the Democrats, but that they are open to a proposal that would include reforms and cost cuts.

“I think what Jay Barnes’ plan is is an opportunity to keep the door open,” he said. “You never know what is going to come down or how politically things change, plus it is an opportunity to look at a broken system and think of ways to improve it.”

Behind the scenes, consultants — some of whom work actively for Republicans — have led an information push in which they have briefed Republicans on the political benefits of expansion. The Missouri Hospital Association, one of the groups leading the charge for expansion, commissioned a poll that found a plurality of Missourians — 47 percent to 37 percent — favor expansion. That number rose 5 percent when those polled were offered a set of arguments for and against the proposal.

The poll, taken in February by American Viewpoints, a firm that many Missouri Republicans have used in the past to conduct their own internal polling, found that Medicaid expansion is favored by independents and women, and is even supported by a plurality of Republicans when it is coupled with a set of reforms.

Nixon had recommended spending nearly $1 billion of the federal funds in fiscal 2014 to expand Medicaid coverage to an estimated 260,000 adults.

In a play for support from moderate Republicans, Nixon has repeatedly touted expansion as not only the right thing to do morally, but the right thing to do economically. Nixon’s office said last week that 30 business groups, including the Missouri Chamber of Commerce, have indicated their support for expansion.

Expansion, or lack of expansion, also could have an impact on rural Missouri. The Missouri Budget Project, a Democratic think tank, along with Washington University’s Timothy McBride and Saint Louis University Law School’s Sidney Watson, found that while expansion would cover Missourians in urban areas, it would have a greater impact on reducing the number of uninsured residents in rural Missouri. Expanding the program would lower the portion of uninsured Missourians by 29 percent in Southwest Missouri and 31 percent in Southeast Missouri, the study found.

The federal law, under the assumption that more people would be placed in the Medicaid system, would cut disproportionate share funds, which are used to offset the cost of those who are uninsured. But in 2020 — when the law assumes Medicaid will be expanded — those payments are set to be largely phased out, leaving hospitals on the hook.

Flanigan said hospitals and the Obama administration “made a deal with the devil” when putting the law together, and he is not really concerned that they’re “getting the other side of the deal they made.”

“The deal made with the devil on DSH (disproportionate share hospital) payments was not made with the Missouri House,” he said. “That was a federal thing between the Obama administration and the National Hospital Association.”

The fiscal 2014 budget plan now goes to the Senate, where changes are likely. The Legislature faces an early May deadline for approving a budget


WHILE GOV. JAY NIXON has made expanding the Medicaid program a top priority, Republicans in the General Assembly do not necessarily feel a sense of urgency. House Speaker Tim Jones said Thursday that he is watching Rep. Jay Barnes’ bill and is on board with trying to cut back on some of the costs of the program.

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