Discord has emerged among Missouri Republicans who for years have been united against a Medicaid expansion or anything that smells of Obamacare.
That schism boiled up in legislative debate this week, serving as fresh evidence that while few would bet on Missouri expanding eligibility for the federal health insurance program this year, resistance could be wavering.
“Until now, there’s been a brick wall between the Democrats and Republicans, and no one has come over to the side of trying to find a compromise that would fit for Missouri,” said Senate Minority Leader Jolie Justus, a Kansas City Democrat. “For the first time, I truly feel like there is a path forward and that expansion is going to happen.”
Efforts by some Republican legislators to rework and expand Medicaid still aren’t likely to succeed this year. But their push has revealed fissures in the GOP blanket objection to anything spinning from the Affordable Care Act.
At the same time, though, their efforts have demonstrated that key opponents remain as committed as ever.
“I will stand with my colleagues and stop any push for expansion,” said Sen. Rob Schaaf, a St. Joseph Republican and a family physician. “There is no pathway by which Medicaid expansion will occur this (legislative) session.”
The politics of Medicaid expansion in Missouri have always been complicated. To be eligible for Medicaid in Missouri currently, a non-elderly adult must have a dependent child and can earn no more than 19 percent of the poverty level — roughly $3,700 for a single mother with two children.
Under the federal health care law, states that expand Medicaid eligibility to those earning up to 138 percent of the poverty level can initially receive full federal funding for that group, with the federal share gradually scaling back to 90 percent.
Without expansion, those earning between 19 percent of the poverty level and 138 percent will qualify neither for Medicaid nor federal subsidies to help them purchase private insurance.
Around 200,000 Missourians fall into that coverage gap.
Democrats have pushed for expansion alongside traditionally Republican groups such as the Missouri Chamber of Commerce and Industry. They have argued that expansion would provide coverage to uninsured Missourians and that doing so would inject billions of additional federal dollars into the state’s economy.
On the other side are conservative activists and lawmakers who believe it’s unwise to add to the national debt while putting more people in the care of a social safety net.
A group of House Republicans, led by Reps. Noel Torpey of Independence and Jay Barnes of Jefferson City, has been pushing for fellow lawmakers to accept federal money for expansion while implementing reforms in the Medicaid system.
That effort has gained traction in the House but has run into fierce opposition in the Senate.
Two weeks ago, five Republican senators — led by John Lamping of St. Louis County and Kurt Schaefer of Columbia — declared they would use the filibuster to kill any measure that adds people to the Medicaid rolls.
“This is done. It’s not happening,” Lamping said to expansion proponents. “Go find something else to do.”
On Wednesday, during a heated debate on the Senate floor between Lamping and a fellow Republican, Sen. Ryan Silvey, differences within the GOP bubbled over.
“I’ve just grown weary of those who want to toss their hands up and throw labels around instead of digging into the details of trying to solve the problem,” said Silvey, a Kansas City Republican. “You have people who are more interested in sound bites and more interested in obstructing than they are in realizing what the reality of the situation is and dealing with it.”
Silvey has begun circulating a plan that would use federal money to help finance private health insurance for low-income adults. It also would implement changes, long pursued by Republican lawmakers, to the Medicaid system and entitlement programs like food stamps. Among the changes are work requirements for those receiving aid.
“If we were to put these ideas on the governor’s desk right now, they would get vetoed,” Silvey said. “But as part of a comprehensive reform package of the state’s welfare system that includes some sort of expansion, I think he’d have to sign it.”
Lamping, who has decided not to run for re-election this year, said advocates for expansion are now trying to use reform as a smoke screen. Republicans must stand firm, he said, against anything stemming from the federal health care law.
“Being fiscally conservative isn’t easy,” Lamping said. “It’s a hard job.”
Democratic Gov. Jay Nixon, who supports Medicaid expansion, has estimated that Missouri could save money by switching some people whose health care is covered by state funds into the new federally funded Medicaid category.
Silvey said those initial savings could be stockpiled to help cover the state’s future costs. If that doesn’t provide enough money, Silvey said, future state costs could be covered by reducing the state’s reimbursement rate to hospitals.
For those living below the poverty level, Silvey’s plan would provide coverage through managed care insurance policies. The state would use federal Medicaid money to subsidize private insurance plans for those who live above the poverty line. Recipients would be encouraged to work and be mandated to pay premiums and copays in many instances.
Any changes made to the Medicaid system will hinge on getting a waiver from the federal government.