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Nixon makes strong push for Medicaid expansion, faces stiff challenge in GOP-controlled legislature

3:19 pm on Thu, 11.29.12

Gov. Jay Nixon announced his full support for expanding the state’s Medicaid program, a key provision of the Affordable Care Act that he contends will bolster the state's economic fortunes and help an estimated 300,000 poor Missourians get access to health care.

But the Democratic governor’s advocacy could face a steep challenge in the Republican-led Missouri General Assembly, unless GOP legislators make an about face from their decision in 2005 to cut eligibility for the health-care program for the poor.

When Nixon first campaigned for governor in 2008, he said he would make restoring Medicaid cuts one of his major priorities. But then, after he was elected, he did little -- aside from a failed 2009 effort -- until today.

Gov. Jay Nixon announces his support for a Medicaid expansion at the BJC Outpatient Center in St. Louis.
Jason Rosenbaum I St. Louis Beacon
Gov. Jay Nixon announces his support for a Medicaid expansion at the BJC Outpatient Center in St. Louis.

Speaking at the BJC Outpatient Center in St. Louis, Nixon said he supported expanding eligibility for Medicaid to those earning up to 138 percent -- from the current 19 percent -- of the federal poverty level.  According to his office, that would mean a family of four making $31,809 a year would be eligible for the program.

"Make no mistake: The path we choose will affect the health of hundreds of thousands of Missourians and the future of our state's economy," Nixon said. 

Under the ACA, the federal government would fund 100 percent of the expansion from 2014 to 2016. After that, Missouri would gradually pick up a share of the cost until it funds 10 percent of the expansion by 2020. The U.S. Supreme Court decision earlier this year made expansion optional, meaning that states could opt out.

Nixon – who said he would include the expansion in his 2014 budget – echoed a report released Wednesday by the Missouri Hospital Association and the Missouri Foundation for Health about the expansion's economic impact. Those two groups told reporters that the expansion would create thousands of jobs, increase state and local tax revenue and lower the costs of private insurance premiums.

But, as the governor emphasized several times during his speech to a packed audience, expanding the program was “the right thing to do” for the state – especially for Missouri’s uninsured residents.

“This is not the time to reopen the debate or re-argue the merits of the act,” Nixon said. “Congress passed it. The president signed it. The U.S. Supreme Court upheld it. It is the law of the land. Today, we stand with a clear choice before us:  The choice is not whether to follow the law but whether to implement it in a way that provides the greatest benefit for the people of Missouri.”

Specifically, Nixon noted how the ACA reduces payments to hospitals in the next decade. If the state doesn’t expand Medicaid, he said, those providers would be hard hit.

“Under the Affordable Care Act, payments to hospitals that serve the uninsured will be dramatically reduced,” Nixon said. “If we don’t take action now, they stand to lose hundreds of millions of dollars – putting them at risk in some communities and closing them altogether.”

Steven Lipstein
Steven Lipstein

And the cost could be to more than just the facilities themselves. BJC President Steven Lipstein told reporters after Nixon’s speech that people with insurance would bear the brunt of a decision not to expand Medicaid.

“When we do take care of patients that don’t have health insurance, we still pay our staff, we still pay for the medicines, we still pay for all the supplies,” Lipstein said. “And what we do is shift that cost to the people who do have health insurance. So if the legislature does decide not to expand the Medicaid program and hundreds of thousands of Missourians continue to be uninsured, we will continue to shift that cost of care to all the commercial insurance premium payers here in the state of Missouri -- instead of the cost being borne by the federal government as the governor outlined in his remarks today.”

Nixon’s decision was praised by organizations representing health-care providers. Joseph Pierle, the CEO of Missouri Primary Care Association, praised Nixon in a statement for “pushing for health-care coverage for the working poor and ensuring healthy economic growth.”

Claire McCaskill
Claire McCaskill

And his announcement was also well-received by his fellow Democrats, including U.S. Sen. Claire McCaskill. The recently re-elected senator said in a statement, “Expanded coverage will boost the number of Missourians with access to life-saving health services, expand job opportunities, and protect rural hospitals, which are at risk of closing from fiscal challenges.”

“The next step is for the folks in Jefferson City to follow our lead,” McCaskill said. “The legislature should act now to support the Medicaid expansion, and create a Missouri-based health insurance exchange instead of handing its creation over to the federal government. I honestly never thought I’d see the day when the Missouri Legislature would willingly toss responsibility back to Washington and walk the other way.”

Renewed battle

McCaskill’s statement alluded to the practical hurdles Nixon faces in pushing for the expansion.

Republicans hold commanding majorities in both the Missouri House and Senate, and the party has been adamant in the past about not expanding Medicaid.

Gov. Jay Nixon answers questions about how he will get General Assembly Republicans to expand Medicaid.

In fact, Medicaid eligibility was for years the political dividing line between the state’s two major parties. That was especially the case after 2005, when GOP Gov. Matt Blunt and the Republican-controlled General Assembly made deep cuts to the program.

While Republicans defended the move as a fiscally prudent decision after years of budgetary woes, Democrats cast it as an expensive and shortsighted move because the uninsured would wind up using emergency rooms for care. Nixon made expanding Medicaid a key plank of his 2008 gubernatorial campaign and attempted a modest expansion of the program during his first year in office.

That effort went nowhere in the Republican-controlled legislature, and Nixon stopped pushing. During the past election season, Nixon was decidedly mum on the issue.

"Blunt got creamed for cutting Medicaid. And that was in part responsible for Nixon’s election, if we go back to that," said Missouri State University political science professor George Connor. "And I think that’s also one of the reasons that Blunt didn’t run for re-election because he was still feeling the singe of those actions. And they might have been necessary. I won’t get into the whole budgetary thing. But certainly Nixon exploited those cuts for political gains. But he’s not been able to restore any of those cuts, let alone expand Medicaid coverage." 

Asked how he would convince Republicans to go along with expansion after years of opposition, Nixon said, “I think most folks believe if Missourians pay dollars in taxes, they should receive the benefit of that.

“We shouldn’t pay our tax dollars here in Missouri so that other portions of the country to spend those,” Nixon said. “The other thing I think that’s important for folks to understand… is that the ending of these 'disproportionate share dollars' (the payments to hospitals for treating the uninsured). That’s a significant penalty especially in many rural areas of the state where hospitals have many challenges to deal with. I think that’s important.”

Thus far, Republicans leaders have been decidedly negative to the prospect of expanding the program.  The call to expand Medicaid is coming as GOP legislative leaders are calling for business tax cuts that could cut the state's revenue by at least $200 million a year.

Senate President Pro Tem Tom Dempsey, R-St. Charles, said earlier this month his caucus would likely not support the expansion. And House Speaker Tim Jones, R-Eureka, said in a statement that now is “not the time to put our state on the end of yet another big government program that will only increase the burden on future taxpayers.

Tim Jones
Tim Jones

“My first question to the governor is this: Where is the money to pay for this once the federal aid goes away?” Jones said. “The federal government is providing the funding now, but it is likely to disappear in just a few years as our nation comes to grips with our crippling national debt. That would leave Missouri taxpayers holding the bag for a massive expansion of a very expensive entitlement program, and that is unacceptable.

“I am not going to be like so many other politicians and pass a program just for the immediate results while leaving someone else to pay for it down the road,” he added. ”This is not prudent and is not how Missouri budgets taxpayer money.

While health-care providers may put pressure on Republicans, Connor said, Nixon faces a tough task in persuading the legislature. 

“While this is perhaps Nixon’s best chance to restore and expand Medicaid coverage, my guess is he’ll have an enormous amount of difficulty politically to do so,” Connor said. “It wouldn’t surprise me if some Republicans supported the expansion because we’ve had a change of personnel. There are different people in both the House and Senate. But it would surprise me for Republicans as a whole to backtrack that far.”

Asked about Jones' contention that the state couldn’t afford the cost of the expansion after the first three years, the governor said, “A whole lot of folks said stuff during the campaigns.”

“We’ve got a solid argument,” Nixon said. “I think this is a persuasive case on why we should move forward. I remain confident that we’ll work together to find the best fit for the state.

“And the best fit is using Missourians’ tax dollars to hold down the costs of health care, provide jobs to provide access to health care,” he added. “If we stand still and do nothing, we lose money. As we move forward and educate on this case, we can be positively persuasive because it’s the right thing to do.”

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