Paul Nelson works for $10 an hour at a Kansas City car shop, suffers from diabetes and can’t afford the medicine to deal with it.
The working father still earns too much to be eligible for Missouri’s Medicaid program. That’s why he was hoping — praying may be a better word — for an expansion of the program this year so that he could get health coverage.
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“Believe me, it’s rough,” said Nelson, 40.
Despite nearly four months of steady negotiations and a non-stop blitz from Gov. Jay Nixon, expansion of the health care program for the poor — arguably the session’s premier issue — is now regarded as dead, buried and gone. Although a few lawmakers are still pushing the issue, the Republican-led state Senate this week rejected a Democratic attempt to insert $890 million of federal funds into the budget to expand Medicaid to 300,000 lower-income adults.
With final adjournment looming on May 17, that was seen as the issue’s final shot.
“To say that it’s on life support would probably be kind,” said Rep. John Rizzo, a Kansas City Democrat.
“It’s over,” said Rep. Chris Molendorp, a Raymore Republican.
The GOP continues to call expansion unaffordable. But Senate Minority Leader Jolie Justus, a Kansas City Democrat, told her colleagues that it should have been a simple decision.
“Say ‘yes,’ create the jobs, expand the health care, take the money ... we’ve already sent to Washington, D.C., in the form of our taxpayer dollars,” she said. “It’s the right thing to do.”
Expanding Medicaid is a central component of President Barack Obama’s plan to provide health coverage to millions of Americans. Last summer, the U.S. Supreme Court made the president’s Medicaid expansion optional for states.
But the Obama administration dangled a weighty incentive — 100 percent coverage for those added to the program for three years, starting in 2014. After that, the federal share would gradually decline to 90 percent.
Nixon, a Democrat, considered that a no-brainer. He hit the road to build support and held 30 news conferences to promote expansion. He built a coalition of 200 groups that included the Missouri Hospital Association and Republican-leaning chambers of commerce.
It culminated in a mid-April rally at the Statehouse.
“This is our clarion call,” Nixon said then. “This is our moment. 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.”
But to hear lawmakers describe it, any momentum had already drained away. In his new budget announced April 10, Obama indicated that he had changed his mind on a $500 million cut for hospitals that treat lots of uninsured patients. Originally, Obama had said he would eliminate the spending. The heads of small, rural hospitals in Missouri and elsewhere had said that the funding cut would result in the closing of some of those hospitals.
With about half the states still hesitating to expand Medicaid, Obama backed off the cut. While the move sent a wave of relief across the countryside, it also undercut the momentum that had developed to expand Medicaid because the expansion would have replaced the lost funds.
Although final decisions on the cut have yet to be made, Obama’s move stopped expansion talk dead in its tracks in Missouri, particularly among Republican lawmakers whose districts included those rural hospitals.
“Most of my caucus members didn’t understand how expanding a broken system was going to make health care better, but they did understand the threat of having payments to rural hospitals cut,” said House Speaker Tim Jones, a Eureka Republican.
In an interview with The Star, Nixon could scarcely disguise his frustration.
“I was surprised by the action, and it certainly wasn’t helpful,” he said.
A spokesman for the president declined to comment.
That wasn’t the Medicaid issue’s only problem. Silvey said the cost of the existing Medicaid program in Missouri, covering adults making up to 19 percent of the federal poverty level, is rising by $200 million a year — an unaffordable trajectory.
Some lawmakers remain eager to see how Congress will revise funding formulas if a couple dozen states decline expansion. “Let’s see what pressure that puts on Congress to revisit the whole deal,” Silvey said.
Prospects for expansion next year are unclear. Democrats, including Nixon, predict that more Missourians will demand that the state get its share of the Medicaid pie once they see other states benefiting.
Republicans, though, still question costs and what happens after the first three years run out. Gov. Sam Brownback of Kansas, which also is holding out on expansion, has questioned whether the federal government can pay its 90 percent share going forward.
Politicians from both parties, in the meantime, continue to marvel at how vigorously Nixon pursued Medicaid expansion. He didn’t announce his support until after his 2012 re-election win. But once he jumped in, Nixon displayed more gusto for the cause than any issue since he became governor in 2009.
An early February poll by American Viewpoint, which usually surveys for Republicans, found that voters backed expansion by 56-35 percent once they heard “a balanced set of arguments for and against the proposal.”
The pollster’s conclusion: “There are fights that will be had with the governor, but this shouldn’t be one of them.”
Insiders doubt that Nixon’s loss will damage him. The governor, who easily won a second term, appealed to his Democratic base in backing the plan, said University of Missouri political scientist Peverill Squire. “If there are negative outcomes, they will be laid completely at the feet of the Republicans,” he said.
But some Republicans said Nixon hurt his own cause by waiting until after the election to speak out.
“It would have been more impressive if he had come out for it before the election,” said state Rep. Mike Cierpiot, a Lee’s Summit Republican.
The decision not to expand Medicaid this year means Missouri will lose out on one of the three years the federal government will pay the expansion’s full cost.
“It’s a huge loss,” said Andrea Routh, executive director of the pro-expansion Missouri Health Advocacy Alliance. “It’s the people who are the most vulnerable who aren’t getting primary or preventative care. ”
Nixon said Missourians are with him.
“They understand that the choice here is pretty simple,” he said. “Missourians are practical people. They understand the election’s over, the (U.S.) Supreme Court has ruled, and this thing is going forward.”
Nelson has been to the emergency room four or five times in the two years since he learned he had diabetes. He can’t understand why lawmakers are so reluctant to take advantage of free federal money.
“That doesn’t make sense,” he said. “It would help a lot of people stay on top of their health.”
Nelson said he’s supposed to take four shots a day and a pill to control his diabetes. But he’s doing none of it because he can’t afford the medicine.
He wonders whether he can make it another year.
“Who knows what’ll happen between now and next year with myself, let alone 300,000 other people,” he said. “Anything is liable to happen.”