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Medicaid expansion debate could take new turn

JEFFERSON CITY, Mo. — Democrats and Republicans in Missouri elected politics have the same problem: Medicaid expansion. And the solution, which grows more complex every day, may be for both sides to reframe the debate.

For several years arguably the most common theme in the Missouri legislature has been the quixotic charge of Missouri Democrats demanding the state expand Medicaid as called for under the Affordable Care Act. Democrats are currently boxed into historically small numbers in both the House and Senate and have failed to win elections on the issue.

But with potentially billions of federal dollars up for grabs, plenty of groups have been pressuring Republicans for years to embrace expansion, which proponents tout as an economic stimulator that will create thousands of healthcare jobs. Missouri Republicans, though, have long resisted expansion and cited a handful of elections as proof that the people of Missouri are equally resistant.

In 2012, Missouri voters overwhelmingly approved Prop E, which kept Gov. Jay Nixon from creating a state-based healthcare exchange without legislative approval. Coupled with increasing Republican control of the Missouri legislature, and Medicaid expansion opponents have their message: we speak for the people, and the people say no.

But plenty of people are, in fact, saying yes. The Missouri Senate came to a screeching halt last year and made national news when the Human Dignity and Economic Justice Coalition began chanting and singing gospel hymns in the chamber and refused to leave, citing the failure to expand Medicaid as their motivation.

At least half a dozen times since this legislative session has begun, doctors, nurses and patients have flooded the capitol in their trademark red shirts carrying signs demanding lawmakers fills the “coverage gap,” and expand Medicaid. Nationwide, 29 states have expanded Medicaid, and nearly all of the 21 states without expansion have at least one bill before their legislature to do just that.

Just weeks ago, Kansas Gov. Sam Brownback made headlines when he stated, albeit vaguely, that he would be open to Medicaid expansion so long as it didn’t place the state in a financially untenable position. Brownback was just hours removed from two speaking events in Missouri with state lawmakers when the news broke. The news initially ignited expansion advocates, who saw Brownback’s potential support as a major coup, given his conservative chops.

In Missouri, at least some advocates hoped that a neighboring state with a conservative governor making the move would encourage Republicans to rethink their political calculus on Medicaid expansion. For Kansas City-area lawmakers, Brownback’s announcement could place added economic pressure on a region often said to be engaged in a “border war” with Kansas.

“I don’t think it’s unreasonable to say that if Kansas expands Medicaid that some of the Missouri-side businesses are going to seriously consider moving into Kansas,” said Sen. Ryan Silvey, R-Kansas City.

Silvey, the Vice Chair of Senate Appropriations and an expansion advocate, says that Brownback’s tentative support should signal that most of the debate is political, rather than about the best public policy.

“Before President Obama or Obamacare or anything else even existed, this body debated a bill to increase Medicaid eligibility to 225 percent with a staggered premium system,” Silvey said. “Now, that’s much more than what Obamacare calls for, and when that bill was before this body, some of our most conservative members supported it.”


Silvey was referring to “Insure Missouri,” a bill added as a committee substitute to an underlying bill in 2007. The measure was added and supported by then-Rep. Rob Schaaf, who is currently a state Senator from St. Joseph. Schaaf’s bill, according to Silvey, is Medicaid expansion “plain and simple.” Schaaf has long stood as an opponent of expansion, promising to filibuster any measure.

Silvey, in what can only be called a move in political trolling, filed Schaaf’s “Insure Missouri” bill from 2007 “word for word” this year. He doesn’t intend for it to pass, but says it’s proof that opposition to expanding access to Medicaid is “completely political.” SB 566 has not yet been referred to committee.

Silvey and Schaaf clashed briefly last week over a bill that Schaaf is sponsoring. SB 295 would expand eligibility to Medicaid in Missouri to 100 percent of the federal poverty level for the elderly and disabled. The measure has a $100 million fiscal note by 2018. Silvey claims the bill was “just for show,” on the part of Schaaf, an effort to appear to care about the elderly and disabled, without taking action.

A hearing was held on the bill in the Veterans Affairs and Health Committee in mid-February. Since the hearing, Schaaf hasn’t moved to hold a vote on the bill despite publicly supporting it. Silvey made a motion during committee last week to vote on Schaaf’s bill, but Schaaf moved to adjourn before a vote was held. Schaaf did not respond to requests for a comment.

As the political opposition to Medicaid expansion becomes more engrained, advocates have to begin to consider other options. Republicans, still facing two more years of a Democratic governor unafraid to veto their priority legislation, may begin to consider Medicaid expansion not as a line in the sand, but as a uniquely valuable bargaining tool.

Republicans have a series of legislative priorities that simply can’t get past Nixon’s veto pen unless, perhaps, they have something to trade. Some advocates of higher tax cuts, voter ID laws, and Right-to-Work are now quietly encouraging legislative leadership to use Democrats “obsession” with expansion as a bargaining chip to force the governor and the minority party to allow some Republican-backed measures to become law.