Is Mo. Medicaid expansion a possibility in 2015?

What would it take to pass Medicaid expansion in Missouri? It’s a question legislators and lobbyists alike are tackling during the summer recess.

Despite a big push from organizations such as the Missouri Chamber of Commerce and Industry and the Missouri Hospital Association, legislators declined to pass any bills addressing the issue for the second straight year.

The idea has divided Missouri Republicans, with some, such as Sen. John Lamping, R-St. Louis County, standing opposed no matter what. Opponents site potentially disappearing federal funds as the main offense.

The effects of legislator inaction recently have begun to surface, and employers such as St. Louis-based health care system Mercy plan to cut 200 to 300 jobs later this month, citing among other reasons, the failure of Medicaid expansion.

“I wouldn’t be surprised if the cuts continue,” said David Dillon, vice president of media relations for the Missouri Hospital Association. “In the last year and a half, 1,000 jobs have already disappeared in the health care sector.”

Mercy’s staff cuts locally are unknown, but at CoxHealth, the system shed 10 employees since January 2014 through standardization of practices brought on by low funding due to pressures created by the Affordable Care Act, sequestration and the failure of the Medicaid expansion, said spokeswoman Michelle Leroux.

A recent economic impact study by the Missouri Economic Research and Information Center shows a significant boost for the Show-Me State economy should Medicaid expansion prevail.

According to the analysis, the expansion of Medicaid eligibility for adults earning up to 138 percent of the federal poverty level would result in the creation of 23,868 jobs, $9.9 billion in new wages and $14.6 billion in new gross state product between 2015 and 2022. Medicaid expansion also would generate $402 million in new state general revenue 2015-22, including $53 million in new general revenue in 2015, according to the study.

Sen. Bob Dixon, R-Springfield, said he can’t predict what the 2015 session will bring, but he’s optimistic Medicaid expansion will have the best chance it’s ever had during the upcoming session.

“We are coming off one of the most productive sessions I’ve seen in 12 years. There was more harmony between the legislature this year,” he said. “We made progress and with the right set of reforms, this has a chance.

“Also, some of those legislators who stood opposed won’t be back next session.”

Medicaid transformation
Dixon said the idea of Medicaid expansion hinges on reforming the program in the state as a whole, what he terms a Medicaid transformation.

“Several things need to happen for this to work,” he said. “I’ve said people need to have some skin in the game and that happens through small co-pays, maybe $2 or $3.

“Providers I’ve talked with say there is zero incentive to keep an appointment. Those canceled or missed appointments cause a scheduling nightmare for the doctors and other paying customers.”

That’s a step the state can’t take without a federal waiver, a move Dixon said many states already have made and been approved for, with the exemption for those under 138 percent of the poverty level.

Adding a work requirement is another step Dixon feels adds skin to the game.

“I’ve talked to so many disabled residents who don’t understand why they can’t qualify for benefits and feel services are cut from them by able-bodied people who could be working,” he said. “It’s reasonable and makes sense.”

Third, Dixon also believes expansion should come with a time stamp.

“Part of the apprehension going forward is what happens when the federal money is gone?” he said. “We can’t pave our roads properly and fund our classrooms as it is right now. Nobody wants to go down that road.”

Dixon said a sunset policy would be a way to move the legislation forward but also “hold the federal government’s feet to the fire.”

“When the sunset hits, we could then go and remake the system based on what federal funds look like at that point,” he said. “Most people are willing to look at reform. A sunset policy would be our insurance.”

Legislative moves
According to a joint statement from the MHA, state chamber, Missouri Primary Care Association and Missouri State Medical Association, “A ‘Missouri solution,’ including both reform and expansion, has a legislative champion in each chamber.”

Dillon said MHA’s goal is to refine the legislation during the coming months.

“At this point, there isn’t a specific list of options a Missouri approach needs to include, but everyone involved is looking at the structure of what expansion means,” he said.

“We are working like it’s still the session to build momentum and get bills prefiled in December.”

Rep. Elijah Haahr, R-Springfield, said the power to pass might lie with the Senate.

“Last session, there were a number of senators who flatly said they wouldn’t discuss Medicaid expansion,” he said. “It’s hard to meaningfully discuss these things in the House when the Senate won’t even consider them.”

After battle lines are drawn in the sand, Haahr said it’s hard to find compromise.

House Bill 1901 died in committee after a Republican split and lack of support from the Senate.

“They need to show they work through the differences before this can go anywhere,” he said.

When asked about Dixon’s Medicaid transformation view, Haahr said he agreed significant reform must take place, noting he expected the House to consider Medicaid expansion in 2015.

He said everybody is in wait-and-see mode.

“There is no doubt this is an issue,” he said. “The conversations are starting again. That’s a big step in itself.”

With more changes to the federal Affordable Care Act released monthly, Dixon said the health care sector is in a state of flux no matter what Missouri decides.

“If the state expands or not, it will have a small impact on the overall changes we are seeing 10 or 20 years from now,” he said. “In the short term, it’s easy for hospitals to point toward a lack of expansion, but the same could have been said five years ago.

“The real answer here is to have a renewed emphasis on job creation. Economic development and investment in jobs should be our focus.”

Dillon said in the meantime, the Missouri business community picks up the tab for the large uninsured population, to the tune of $1 billion a year.

“This is a bread and butter issue for Missouri,” he said. “We can’t afford not to do it.”

Reporter Brian Brown contributed to this article.