Bob Onder hasn’t been sworn in as a state senator yet, but his first priority is already clear.
“Fighting the effects of Obamacare in Missouri is at the top of my legislative agenda,” Onder said.
The only bill the Republican from St. Charles has filed so far would strip an insurance company of its license to sell policies in Missouri if it were to accept federal subsidies for plans sold through Missouri’s federally run health exchange.
But he doesn’t intend to stop there. Onder also made another campaign promise regarding the federal health law that he intends to keep.
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“I will do everything I can,” he said, “to prevent Medicaid expansion.”
As it turns out, keeping that promise probably will be pretty easy.
Legislative leaders in the Missouri House and Senate have said any discussion of Medicaid expansion is off the table in 2015. A group of Republican senators has promised to filibuster expansion if it somehow did get traction.
Even expansion’s loudest boosters don’t see much cause for hope in the short term.
“If (legislative) leadership doesn’t want to talk about it, then there’s not a whole lot that can be done,” said state Sen. Ryan Silvey, a Kansas City Republican who sponsored an expansion bill during the 2014 session.
The Republican-dominated General Assembly has repeatedly balked at the idea of accepting billions of federal dollars to offer Medicaid coverage to around 300,000 uninsured Missourians — a key provision in the federal health care law.
Opponents of the idea have expressed concerns about the long-term costs, both to the federal and state governments. They also object to expanding the number of people in the Medicaid program without dramatic changes to how it functions.
“To expand Medicaid would only put further stress on a system that’s already strained,” Onder said.
Those arguments have won the day. And with expanded GOP majorities in both legislative chambers, that’s not likely to change anytime soon.
“Take a look at the elections,” incoming House Speaker John Diehl, a Republican from the St. Louis suburbs, said shortly after his party won its historic veto-proof majority. “Clearly, on the federal level, Obamacare has been rejected by the voters of this country and … it’s also been rejected by the voters of this state.”
While odds are long for success, proponents of expansion continue to lean on two factors they hope will sway skeptical lawmakers.
The first is a coverage gap.
Currently, to be eligible for Medicaid in Missouri, a non-elderly adult must have a dependent child and can earn no more than 19 percent of the poverty level, or roughly $3,700 for a single mother with two children. Federal tax credits help offset costs of insurance for those earning between 138 percent and 400 percent of the poverty level.
Medicaid expansion was supposed to cover the 200,000 Missourians earning between 19 percent of the poverty level and 138 percent. As things stand, though, they qualify neither for Medicaid nor federal subsidies to help them purchase private insurance.
That means a family of four earning up to $95,000 a year qualifies for assistance. A similar family earning $32,000 doesn’t.
The second concern of proponents is the phasing out of federal funding for hospitals to offset the costs of providing care to the uninsured.
When the federal health law was written, it was assumed hospitals would no longer need that money because the previously uninsured would have either subsidized private coverage or Medicaid.
The Missouri Hospital Association has warned rural hospitals will face huge cutbacks, or even closure, without Medicaid expansion.
“It won’t be the president that closes rural hospitals,” said state Rep. John Rizzo, a Kansas City Democrat. “It will be the rural legislators themselves who opposed Medicaid expansion.”
Silvey says simply expanding Medicaid would be a mistake. But he said the state shouldn’t stand by while rural hospitals close and the working poor remain stuck in the coverage gap.
“We have to govern in the world we live in,” Silvey said, “not the world we wish we lived in.”
Besides, Silvey said, Republicans can achieve a litany of long-sought changes to the state’s welfare system if they are tied to expansion.
Last session he helped put together a plan that would use federal money to help finance private health insurance for low-income adults. It would also implement changes to Medicaid and other entitlement programs such as food stamps.
“These reforms individually would face a filibuster or 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 they could become law.”