What’s next on Missouri's Medicaid expansion front?

But that doesn’t mean Medicaid expansion is dead in Missouri.

The federal Affordable Care Act calls on states to expand eligibility requirements to cover more people. If they agree, the federal government will pick up most of the costs. Gov. Jay Nixon, a Democrat, strongly favors the expansion, but Republicans who control both chambers in the Legislature have so far opposed it.

However, Republican lawmakers have shown deep interest in reforming Missouri’s Medicaid program to make it more efficient. And during debates in the House over the issue last week, several appeared willing to accept some form of expansion if it helps them accomplish that goal.

“The majority of us want a solution, and we are willing to work for it,” Rep. Kevin Engler, R-Farmington, said. “Just to say, ‘We should expand it,’ is not a solution. Let’s try to make it better.”

Nixon, for his part, has signaled a willingness to accept efficiency changes if they are accompanied by the expansion.

Republican Rep. Jay Barnes of Jefferson City has sponsored a bill that would attempt to do both. It uses the federal government’s expansion offer as a starting point to retool the health care program for the poor. But Barnes’ measure doesn’t go as far toward raising the income limit for Medicaid eligibility as the federal law directs.

Currently, more than 850,000 Missourians are on Medicaid, which has varying degrees of coverage based on income. The federal government pays part of the costs, but the state currently spends nearly half of its general revenue dollars on Medicaid each year.

The federal expansion model would set eligibility at 138 percent of the poverty level, or about $15,800 for a single person or $32,500 for a family of four. Under that plan, the federal government would pick up all of the costs of new enrollees for the first three years and scale back to a 90 percent match by 2020.

Barnes’ plan instead calls for eligibility at the poverty level, which is $11,490 for a single person or $23,550 for a family of four. It is unclear whether the state would still qualify for the full federal funding outlined in the health care law under Barnes’ plan.

Nixon has staked significant political capital on expanding Medicaid, making more than two dozen appearances across the state in recent weeks to speak in favor of it. His official Twitter feed is mostly dedicated to promoting Medicaid expansion. And it was the highlight of his State of the State speech in January.

Nixon recently said in a written statement that he backs efforts to make the system “as efficient and effective as possible” through the expansion and reform, and he’s willing to work with the Legislature to do so. He is backed by health and business groups throughout the state, many of which have been allies of Republicans on other issues.

House Speaker Tim Jones, R-Eureka, repeatedly has spoken about the need for “transformation” over a straight-up expansion, but last week he gave reporters a two-page, single-spaced written statement that delves deeper into his views.

“The undeniable truth is that we do want to ensure access to quality health care for our most vulnerable citizens,” it reads. “We simply refuse to put our stamp of approval on a massive expansion of a badly broken Medicaid system that fails to provide basic, baseline care to current participants and is a terrible value for taxpayers.”

Jones’ statement details some of the problems he sees in the current program, claiming that people on Medicaid receive poorer quality care than those with private insurance and that doctors don’t want new Medicaid patients because the reimbursement rates are too low.

“Also problematic is the fact that the system is devoid of any competition or incentives to improve care, contain costs and save taxpayer dollars,” he wrote.

His comments are reflective of the views that several Republicans expressed on the House floor during budget talks.

Rep. Jeff Grisamore, R-Lee’s Summit, told colleagues he wants to see “a transformed and reformed Medicaid that’s cost-effective and care-effective.”

Senate Republican leaders recently issued a statement, signed by seven ranking members of the chamber’s majority caucus, that called Medicaid a “broken system,” but the senators expressed an openness to some form of compromise, even one that draws the federal dollars.

“The majority caucus of the Senate will continue to review and discuss any and all responsible proposals that would provide more effective and responsible delivery of vital health services to our population,” their letter states.

Democrats say they are open to the reform proposals.

“We should be embracing this opportunity to make changes to the system to improve it and use federal dollars to do so,” said Rep. Kevin McManus, D-Kansas City.

House Minority Leader Jake Hummel, D-St. Louis, said he’s also willing to work on reform proposals and semantics. “Let’s call it something else. Let’s call it ‘transformation.’ You can call it whatever you want,” he said.

State lawmakers have to appropriate federal dollars through the budget, but the spending plan approved by the House this week is far from a final product. The budget now goes to the Senate, and the two chambers will hash out their differences by early May.

Barnes’ bill includes several changes in the program that he says would make it more efficient, including a shift to private managed care systems, an added push toward preventative care and financial incentives for recipients to keep their health care costs low. If it passes the Legislature, it will still require multiple waivers from the federal government.

U.S. Health and Human Services Secretary Kathleen Sebelius has said the federal government won’t agree to pay higher match rates for new enrollees if states don’t go to the full 138 percent, and some legal experts have questioned whether the federal government has the legal authority to cover for states with smaller expansion plans.

But Barnes has been cool to suggestions from some Democrats that he raise the eligibility level in his bill to match the federal guideline. Rep. Todd Richardson, R-Poplar Bluff, said he thinks the state should first see whether the federal government will agree to 100 percent, and Jones has said repeatedly that he doesn’t think that eligibility should be lifted to 138 percent.

Some Democrats and other expansion advocates are holding out hope that the reform elements will make the higher eligibility level more appealing at some point.

“I think they know they have to get to 138,” Hummel said. “I guess we’ll wait and see if the majority is serious about working on a bipartisan bill.”

Lawmakers are already halfway through the session, and some Republicans, including Jones, have floated the idea that the Medicaid effort could take more time. Under the health care law, the expansion is supposed to take effect Jan. 1, so the state would lose its first year of fully-federal funding if the issue isn’t resolved before then.

Hummel said Nixon told Democrats in a meeting Thursday that he’s not yet considering a special session to get the expansion through.

“He wants it done now,” Hummel said.