Analysis: Mo. Medicaid expansion unlikely in 2013

JEFFERSON CITY, Mo. -- Addressing a revved-up audience at the Missouri Capitol, Gov. Jay Nixon last week passionately implored the masses to make their desires for Medicaid expansion known to reluctant state lawmakers.

The crowd, which Nixon estimated between 1,000 and 2,000, enthusiastically applauded.

Two days later, a total of just five people testified before a Senate committee in support of a Medicaid expansion. And one of those essentially conceded defeat.

With time running short in Missouri's legislative session, what many presumed at the start now seems increasingly clear: Missouri will not expand Medicaid health-care coverage for the poor, at least not during the annual session that ends May 17.

"I think it's safe to say that Medicaid transformation is not happening this year," said Rep. Jay Barnes, of Jefferson City, the sponsor of a Republican alternative to the Medicaid expansion backed by the Democratic governor.

The 2010 health care law enacted by President Barack Obama relied upon the joint federal and state Medicaid program as a primary means of providing health coverage to millions of Americans lacking insurance. A Supreme Court ruling last summer made Obama's Medicaid expansion optional for states. But it left a financial carrot -- three years of full federal funding, starting in 2014, for states that raise adult eligibility to 138 percent of the poverty level, about $32,500 for a family of four. After that, the states' share would gradually rise to 10 percent of the costs by 2020.

Missouri's Republican legislative leaders responded to the court ruling by immediately declaring they would not expand Medicaid. Nixon initially remained silent. Then shortly after winning re-election last November, Nixon announced his support for the Medicaid expansion, calling it both "the smart thing" and "the right thing to do."

Over the ensuing four-and-a-half months, Nixon held more than 30 news conferences around the state promoting the Medicaid expansion. He teamed up with doctors and hospital administrators, local Chamber of Commerce officials and law enforcement officers, and advocates for the poor and mentally ill to build a coalition of about 200 organizations. Those efforts climaxed Tuesday, when a crowd converged on the Capitol for a massive lobbying effort capped by a nearly one-hour pep rally with Nixon as the keynote speaker.

"This is our clarion call. This is our moment," Nixon declared. "With your help, we will look back on this day as the beginning of a brighter, healthier opportunity for our state -- not an opportunity that passed us by."

Yet at that moment, the prospects of passing a Medicaid expansion this session already had faded. In another part of the building, House Speaker Tim Jones, R-Eureka, had just told reporters that he believed a supermajority of Missourians "do not want us to implement any form of Obamacare in this state."

Republican lawmakers repeatedly had defeated Democratic efforts to expand Medicaid in the weeks before Nixon's rally. Several other developments last week may have sealed its fate.

* The Senate Appropriations Committee endorsed a budget plan that, as in the House, leaves out more than $900 million of federal money Nixon had requested for the expanded Medicaid program. The full Senate is to debate the budget starting today. But Republicans, who hold a two-thirds majority, have no plans to restore the Medicaid money.

* Barnes, who leads a committee that endorsed an alternative Medicaid plan on April 3, has stopped pushing the bill. Barnes said he asked the chairwoman of the House Rules Committee not to bring it up for a vote. He cited the Senate's opposition as a reason.

"I don't carry bills and work hard on bills that I think have no chance," he said.

* Senators, who already opposed the Medicaid expansion, said a recent proposal by Obama removed any urgency to act this year. Obama proposed to delay a scheduled funding cut to hospitals that treat the uninsured until 2015. Nixon and Missouri hospital administrators had touted the Medicaid expansion as a means of saving hospitals from financial peril.

"The fact that the federal government has recommended extending the [uncompensated care] payments to hospitals for a year really bought us some time," said Sen. Dan Brown, R-Rolla.

A Senate health committee led by Brown heard testimony Thursday on a Medicaid expansion bill sponsored by Democratic Sen. Jamilah Nasheed, of St. Louis. Nasheed quoted Biblical passages about caring for the poor while asserting that all "God-fearing people" should support a Medicaid expansion. But unlike previous Medicaid hearings, which drew as many as 30 supportive witnesses, just five people spoke in favor of Nasheed's bill.

Missouri Hospital Association lobbyist David Hale seemed resigned to the bill's failing this session. He shifted his focus to the potential for lawmakers to further study Medicaid changes before the 2014 session.

"We know the dialogue will continue, even into the interim," Hale told senators. "We are open to a multitude of ideas on the subject."