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Opinion: Missouri lawmakers can take one of three roads on Medicaid expansion


As Missouri lawmakers prepare to return to the Capitol in less than two months, huge decisions await us concerning the state’s Medicaid program. While I did not support the Medicaid expansion ballot initiative, I realize the actions we take this legislative session to implement it will impact the state budget, Missourians’ access to care, and our health care industry for decades to come.

Essentially, policymakers have three very distinct options now that voters in early August approved a state constitutional amendment to expand the federal health insurance program for the working poor.

Option one: simply expand Medicaid without reforms and watch the program continue to eat up a larger share of the state’s budget every single year while underdelivering on the health outcomes we need. This is especially concerning to me as our public schools, including those in Southeast Missouri, could potentially take the brunt of the budget damage this would cause.

Secondly, we could simply refuse to expand Medicaid out of principle and concern for the state budget, only to watch as the courts would step in and mandate expansion — and thus, forego our once-in-a-decade shot to reform the program.

As you can see, both of the approaches above end up in the same place — a costly, expanded Medicaid program but without the cost controls to make it financially sustainable in the future and without reforms that actually improve the health outcomes of Missourians.

Meanwhile, we would have fewer dollars in the state budget each year, meaning cuts to K-12 education, job training, higher education, and public safety would be all but inevitable.

That leaves the third and best option: expand Medicaid but only while reforming the program to cost less and deliver better care, while helping rural hospitals like the ones in my district. That’s exactly what many conservative states have done. In fact, Indiana, with Vice President Mike Pence as governor, as well as Ohio, Arkansas, and many other states, coupled Medicaid expansion with a redesigned Medicaid program that cut costs, freed up general revenue, and delivered better health outcomes to the working poor.

These are states Medicaid expansion proponents pointed toward when making claims on the campaign trail that expansion didn’t have to cost an arm and a leg but could instead pay for itself. Those statements are only true if and when we reform our Medicaid program.

Thankfully, there should be bipartisan support for these much-needed reforms. On Oct. 22, the Missouri House Democratic policy chair, Rep. Sarah Unsicker talked about Medicaid expansion by stating, “Missouri also needs to look for savings within Medicaid. We pay more per recipient than other states with similar-sized populations.”

So now is the time to put all good health care reform ideas on the table. Are there areas of the Missouri Medicaid program that should move to managed care? Are there benefits that we currently give to out-of-state patients that need to be cut back? Can we more efficiently use our Federal Reimbursement Allowance to pay for some of the expansion? With hospitals and providers now getting the benefit of Medicaid expansion, do we need to review reimbursement rates?

As we sit here today, I don’t have all the answers, but every single one of these Medicaid reform ideas and more should be analyzed, debated, and discussed during the 2021 legislative session. If come July 1, the mandated legal deadline by which Missouri must implement expansion, we have missed the opportunity to reform our Medicaid program, this session will have been a costly failure that will set our state back for years to come and may directly take money from our public school classrooms.

This is exactly where two of the three roads lead.

However, if this legislative session we can enact reforms that redesign our Medicaid program in a way that provides health care coverage to 230,000 more Missourians in a sustainable, cost-effective way while allowing us to balance the budget and achieve better health outcomes for Missouri families, well, then 2021 might be a very significant year in the history of our state.