Committee hears Republican-backed Medicaid plan

For several months, Missouri leaders have been wrestling with the issue of Medicaid expansion, which became optional for states under the U.S. Supreme Court’s ruling on the federal Affordable Care Act.

Proponents of the expansion say the state will lose out on millions in federal dollars and miss an opportunity to provide health care to thousands of uninsured Missourians if it balks. Opponents, mostly Republicans in the GOP-controlled Legislature, say the proposal is too costly and relies too much on the federal government for support without meaningful reforms to the health care program for the poor.

The House Government Oversight and Accountability Committee met for more than four hours Monday to hear testimony on Rep. Jay Barnes’ alternative to the federal government’s plan.

With half of the legislative session left, the chief disagreements have boiled down to how poor someone should be to qualify for the Medicaid program, which is jointly funded by the state and federal government, and whether the Obama administration will sign off on stricter eligibility requirements.

As outlined in the federal Affordable Care Act, the full Medicaid expansion that has been championed by Democratic Gov. Jay Nixon and health care and business groups in Missouri would set eligibility at 138 percent of the poverty level, or about $32,500 for a family of four or $15,800 for a single person. Under the federal health care law, the federal government will pick up the full tab for new recipients during the first three years and continue paying most of the costs beyond that.

Meanwhile, Barnes’ plan would set income eligibility at the federal poverty level — currently $23,550 for a family of four or $11,490 for a single person. The legislation also includes several reforms intended to cut costs and streamline services — components that aren’t in the federal health care law.

But the proposal hinges on several waivers from the federal government, including one that would allow the state to still access the increased federal match rates through the Affordable Care Act. The bill includes several triggers that would render it useless if the federal government doesn’t go along with the plan.

The House committee is expected to vote on the bill next week. If the committee approves it, the legislation will go to the House floor and then move to the Senate, where leaders have been even more resistant to talks of expanding Medicaid under the federal health care law.

About 880,000 Missourians are enrolled in Medicaid, which has varying degrees of coverage based on income. While it doesn’t go as far as the Affordable Care Act, Barnes’ proposal is expected to add to the state Medicaid rolls several thousand people who aren’t currently eligible.

Several groups, including the Missouri Chamber of Commerce and the Missouri Hospital Association, have come out in support of the full expansion since Nixon announced his support last fall. But Republican leaders in the Legislature have long been critics of the federal health care law and have largely dismissed talks of a full expansion.

The House Oversight Committee and other legislative committees have struck down multiple attempts to expand Medicaid under the Democrats’ plan.

Speaking to reporters Monday, House Speaker Tim Jones, R-Eureka, again stressed his opposition to the full expansion.

“I’m not in favor of going to 138,” he said.

Jones has said he thinks even Barnes’ proposal is unlikely to make it through the Legislature this year and dubbed the effort a two-year project.

“I want to come up with the Missouri solution to Medicaid,” he said. “We’re just at the beginning of this.”

But two legal experts and others involved in the health care industry testified Monday that the federal government is unlikely to approve the waiver that Barnes’ plan needs for increased match rates.

In a letter to governors in December, U.S. Health and Human Services Secretary Kathleen Sebelius said only expansions up to 138 percent will qualify for the additional federal funding provided in the Affordable Care Act.

St. Louis University law professor Sidney Watson, who specializes in health care law, said she doesn’t think HHS has the legal authority to grant waivers to provide the higher match rates. Barnes said he knows of at least one other legal expert who holds the opinion that the federal agency does have the power to, and he’s betting that a political push to try to get more of the health care law through will make the federal government more flexible.

Rep. Todd Richardson, R-Poplar Bluff, said a full expansion in Missouri is “unlikely at best” – so the state’s only options are trying for a partial expansion with Medicaid reform or no expansion and no reform. He said he thinks that tackling the issue of reforming the Medicaid system is significant for the state.

“I’m not sure there is much of a gamble here,” he said. “I’m not sure there’s anything else available.”

During Monday’s hearing, Jefferson City resident John O'Rear told committee members that he thinks the Legislature has become too focused on academics and numbers, and not the people who will be affected by the decision over Medicaid. He talked about his son’s struggles with mental illness and substance abuse.

“For God’s sake, let’s put politics aside,” he said. “Let’s quit worrying about whether it’s Obamacare or whether it’s Barnescare or whose damn care it is. It’s care for our kids.”

In an email blast Monday, the governor urged his supporters to speak out in favor of expansion and reach out to lawmakers.

“Never before in my 26 years of public service, and possibly never again in our lifetimes, will the state of Missouri be able to do so much good, for so many people, at so little cost,” Nixon wrote in the email. “That is why I’ve been traveling to every corner of Missouri — 21 stops so far — to make the case that strengthening Medicaid is the smart thing to do for our economy and the right thing to do for the people of the Show-Me State.”