St. Louis Post-Dispatch, April 22, 2013

A brutal form of cynicism lies behind the latest excuse offered by Missouri Senate Republicans for refusing to even discuss an expansion of the state Medicaid program. The proposal would extend health insurance to poor people and bring thousands of jobs to the state by leveraging billions of dollars in federal investment.

Sen. John Lamping, R-Ladue, was one of several senators to use the word “dead” to describe House Bill 700, sponsored by Rep. Jay Barnes, R-Jefferson City. The bill would both revamp the state’s Medicaid program and seek to take advantage of the promised federal money to pay for it.

If it’s dead, why did it die?

In his 2014 budget filed earlier this month, President Barack Obama proposed delaying $500 million in spending cuts called “disproportionate share” payments. These are the federal payments to hospitals that pay for at least some of the health care costs of the millions of Americans who are uninsured, but end up in hospital emergency rooms for care.

It’s a horribly inefficient system that is being phased out under Mr. Obama’s Affordable Care Act. Because millions more Americans will have insurance, the payments will be unnecessary. The spending on the front end saves us all money on the back end.

Mr. Obama is seeking to delay the cuts specifically because of the intransigence of some state lawmakers, like the Republicans in Missouri, who have ignored both the moral and economic imperatives to find a way to provide insurance to more Americans. If states are slow to implement the ACA, then cutting the disproportionate share payments will be devastating to hospitals, specifically those in rural areas, that will still have to spend millions of dollars on uncompensated care. Those proposed cuts have put pressure on reticent rural lawmakers afraid that major employers in their regions could lose jobs.
It’s key to understanding the moral bankruptcy of the Missouri Republican Party that this is the only motivation that might have persuaded them to keep the Medicaid expansion proposal alive.

Senate Republicans weren’t moved by empirical evidence that uninsured people are more likely to die than those with insurance. In 2009, a Harvard Medical School study found that 45,000 Americans die premature deaths every year in part because they lack health insurance. They weren’t moved by several studies showing that the infusion of $2 billion a year in federal funds each of the next three years will create thousands of health care jobs as hospitals and other health-care professionals increase staffing and investment to help serve more than 260,000 newly insured Missourians. They weren’t moved by the fact that if those 260,000 Missourians remain uninsured, an average insured family of four will pay about $1,688 more a year for health care to cover those costs.

They weren’t even moved by an opportunity to reform Missouri’s Medicaid system and leverage the federal money to move more poor people into the private insurance system.

No, what “killed” the Medicaid expansion bill was Mr. Obama’s proposed budget, a budget that Congressional Republicans called dead on arrival. The circular logic is stupendous in its deception.

First Republicans blame Mr. Obama for the ACA, even after he models it after many of their ideas. Then they spend two years doing their best Walter Mondale impersonation, repeating over and over again, “Where’s the budget?” When the budget is released, of course, they declare it dead. But in Missouri, those same Republicans seize one line of the budget and say, “See? Medicaid expansion is unnecessary!”

Meanwhile, they’re spending their time making sure more Missourians will be in poverty. Not only will poor folks continue entering the health-care system through the expensive door of the emergency room, they also face GOP tax-cut legislation that will further shift the costs of nearly everything toward poor people.
Perhaps we enjoy tilting at windmills, but we refuse to believe that the Missouri Legislature is so bereft of people with a moral commitment to their fellow man that this sort of nihilism can continue ad infinitum.

Why, we recall being impressed when Mr. Lamping told us, back when he was running for office in 2010, that he is guided by the principle set down by St. Ignatius Loyola, the founder of the Jesuit order, that those entrusted with power should make “no decision without considering the impact on the least in society.”

The Medicaid expansion effort is too important to allow it to be blocked, particularly for the Senate’s specious reasons. Gov. Jay Nixon, a Democrat, has done his level best traveling the state, hand in hand with business leaders, most of whom have traditionally supported Republicans, to rally support for this important legislation. But it hasn’t been enough.

It’s time for those business leaders to take a stand. Write some big checks for Democrats and see who comes running. Let Republicans like Mr. Lamping know that their careers are over if they don’t get serious. Let Mr. Nixon know you’ll help him round up the votes to beat back overrides if he starts vetoing every bill that comes to his desk.

Medicaid expansion isn’t about Mr. Obama and it’s not about some consultant-driven debate about future electoral success.

The more people in Missouri who have health insurance, the fewer of them will die. This is literally a life-and-death issue.

Associate Press, April 16, 2013

Rallying with one of the largest crowds of the year at the Missouri Capitol, Gov. Jay Nixon urged activists on Tuesday to implore reluctant Republican lawmakers to expand Medicaid coverage to hundreds of thousands of lower-income adults.

The Democratic governor headlined a nearly hour-long pep rally that his administration says drew more than 1,000 people to the Capitol – a crowd so large that some state employees were asked to park their vehicles elsewhere Tuesday to make way for the busloads of rally participants. The event featured business leaders, doctors, pastors and police officers, all lending their support to the Medicaid expansion called for under President Barack Obama’s health care law.

Nixon, who has been public office for 26 years, praised the proposed Medicaid expansion as the greatest opportunity to do good for the greatest number of people in his political career.

“Let’s make sure that the words we’ve said here are turned into action up there,” said Nixon, pointing upward to the third floor of the Capitol, where the House and Senate chambers are located.

Yet Tuesday’s rally may have done little to change Republican legislative leaders, who repeatedly have rejected a traditional Medicaid expansion while citing concerns about its potential long-term costs.

“In my opinion, a supermajority of Missourians, who I consider my constituents, do not want us to implement any form of Obamacare in this state,” House Speaker Tim Jones, R-Eureka, told reporters as Nixon participated in the rally.

Obama’s 2010 health care law envisioned a Medicaid expansion as one of the primary means of providing health coverage to those currently without insurance. A Supreme Court ruling last summer made the Medicaid expansion optional for states but left in place a powerful financial incentive. States that expand adult Medicaid coverage to 138 percent of the poverty level – about $15,800 for an individual or $32,500 for a family of four – can receive full federal funding for the first three years, starting in 2014. The federal share will be gradually scaled back to 90 percent by 2020.

Nixon says about 300,000 Missouri residents could eventually gain coverage under the Medicaid expansion – a one-third increase in the size of the current program. He also contends the influx of federal money will spur thousands of new jobs and generate more than enough tax revenue and savings to offset the additional state dollars that eventually would be spent on the program.

A Republican-led House committee has endorsed an alternative Medicaid plan that would add some adults to the rolls, though not as many as Obama’s administration has said is needed to qualify for the enhanced federal funding. The GOP plan also would remake Medicaid to more closely resemble private-sector insurance.

But rally participants said it would be foolish to insist upon overhauling Medicaid while delaying the receipt of the federal money.

“Postponing Medicaid expansion until it is perfectly reformed is like leaving shipwrecked passengers treading water and sinking because somebody thinks that the rescue vessel needs some business-process improvement,” said Dr. Heidi Miller, of the Family Health care Center in St. Louis.

Miller predicted that if Missouri waits even one more year to expand Medicaid, doctors and nurses would leave to take more lucrative jobs in states that are enlarging Medicaid.

Among the arguments that Nixon has been making for a Medicaid expansion is the fact that the federal health care law cuts funding to hospitals for the cost of treating uninsured patients beginning in 2014. Without adding those uninsured patients to the Medicaid rolls, hospitals stand to lose money, Nixon has said.

Yet Obama may have partially undercut that argument last week by proposing to delay the federal funding cut to hospitals by a year. Some Republican Missouri lawmakers have cited that as an additional reason not to act this year on a Medicaid expansion.

Lisa Church, a spokeswoman for Bothwell Regional Health Center in Sedalia, stressed Tuesday that Obama’s funding-cut delay is only a proposal.

“I’m afraid that it gives people a false sense of security, and this really is an urgent issue,” said Church, who was near the front of the audience at the rally.

Participants held red-and-white signs that said such things as “Strengthen Medicaid Now” and wore stickers proclaiming: “Full Medicaid Expansion Now.”

Pastor Ron Webb, of Mount Calvary Powerhouse Church in Poplar Bluff, began the event with a praying that legislators “would do the righteous thing, and that’s to vote for Medicaid expansion. “

Springfield New-Leader, March 2, 2013

Kansas City Star, March 1, 2013

Kansas City Star, March 8, 2013

St. Louis Post-Dispatch, March 1, 2013

The St. Louis Beacon, April 2, 2013

The Missouri House has passed a new state budget without Gov. Jay Nixon’s sought-after Medicaid expansion, but that doesn’t mean Republicans are dropping the issue entirely.

The House Government Oversight and Accountability Committee is slated to vote Wednesday on HB700, a bill proposed by state Rep. Jay Barnes, R-Jefferson City, to change the state’s current Medicaid program dramatically.

But word already is circulating that Barnes’ bill, even if it gets through the House, will have a tough time in the state Senate. Fellow Republicans and most Democrats oppose his plan.

Meanwhile, Nixon is continuing to take his pro-Medicaid expansion tour on the road. He was in Wentzville today; last week, the governor was in Kirkwood.

And on Wednesday, the governor plans to be back in the state Capitol to meet with the the House Republican caucus in what is expected to be another pitch to expand Medicaid, as sought by the federal Affordable Care Act.

The federal government would pick up all the additional costs for the first three years, and cover at least 90 percent thereafter.

So far, House Republicans haven’t embraced that plan, instead looking for other alternatives. Which is where Barnes’ proposal fits in.

The House oversight panel conducted a hearing last week on Barnes’ bill, which would result in dropping some people — including children — currently on the rolls and then adding others.

Barnes chairs the House committee and told the Beacon in a recent interview that his bill constitutes “a plan to fundamentally transform Medicaid system into the most market-based system not just in the entire country, but in the entire history of the program.”

Barnes said, “We are attempting to inject price competition into a system that for 45 years has been sorely lacking price competition. So we’re empowering participants to make their own health-care decisions and to do so in a cost-conscious manner that will save taxpayer money.”

Among other things, Barnes’ bill would place income eligibility for the program at 100 percent of the federal poverty level. It would also reduce eligibility in other areas, including children’s health care.

The proposed poverty-line for eligibility is five times the state’s current limit (19 percent) for adult participation on Medicaid, but it’s less than the 138 percent required under the federal Affordable Care Act to receive federal money.

“The areas in which we’re reducing eligibility are populations that are going to have access to robust subsidies in a federal health-insurance exchange,” Barnes said. “So for example, a family of two making about $20,000 a year will have to pay about $34 a month for health insurance. That’s a reasonable cost for somebody to pick up. It will empower them to pick their own plan.”

Barnes’ plan would provide state contracts to competing insurers and would give patients incentives to choose lower-costs plans.

“Study after study has shown people who have private health plans get better health results versus people who are on Medicaid,” Barnes said. “And some of those studies even show that’s true controlling for income. And so we give participants better care – and we do it in a way that’s much cheaper for Missouri taxpayers.”

The legislation is contingent on the federal government granting a waiver to Missouri, Barnes said. That’s important, because one of the tradeoffs of getting the enhanced federal funding is for states to raise the eligibility level to 138 percent of the federal poverty level.

“This is an all or nothing proposition. Either the federal government allows red states to craft solutions that work for them or we don’t do it,” Barnes said. “The fiscal note is either zero – because the Obama administration refuses to back off its ideological stance on a one-size-fits-all Medicaid. Or it’s positive fiscally for over $1 billion over eight years.”

Bill’s fate may depend on feds
Barnes’ plan has sparked a mixed reaction among groups watching the Medicaid battle closely.

Joe Pierle, chief executive of the Missouri Primary Care Association — which backs the Medicaid expansion — said in a statement that Barnes’ bill “is the beginning of a process to bring much-needed stability and predictability to the state’s health-care system.”

Barnes’ bill, he said, “begins to build the framework for a Missouri solution to leverage our federal tax dollars to expand access to affordable health coverage for the working poor.

“Transforming the system and providing affordable health coverage to the working poor are not mutually exclusive,” he said. “Both can be done at the same time.”

Joan Bray — a former Missouri senator who is now the head of the Consumers Council — said in an e-mail to supporters that Barnes’ bill “would introduce a number of changes to the state’s Medicaid program but will never be implemented because the bill expands eligibility only to 100 percent of the federal poverty level.”

“Secretary Kathleen Sebelius of the Health and Human Services Department has made it clear that states will receive Medicaid reimbursement only if they provide service to people with incomes up to 138 percent of the federal poverty level – nothing less,” Bray said. “Without this, Missouri’s bill is meaningless.”

State House Speaker Tim Jones, R-Eureka, released a 1,217-word statement last Thursday that Barnes’ bill “does provide a solid starting point from which we can work toward the kind of Medicaid system our state needs both today and for the years to come.

“Regardless of how we proceed, we will be dependent on the federal government to grant us a waiver that will empower our state to innovate and transform our Medicaid system,” Jones said in his statement. “The way Medicaid expansion was structured by the White House gave states a take-it-or-leave-it ultimatum when it comes to the federal dollars that are available.”

Jones told the press last week, according to a recording from Missourinet, that “we’ve got to work through this process; it’s a long legislative process.”

It’s also unclear whether the House proposal will gain legislative traction. The Columbia Daily Tribune reported earlier this week that Senate President Pro Tem Tom Dempsey, R-St. Charles, said that Barnes’ bill would have a dim chance in the Missouri Senate. Passage in that chamber is key, since bills there can be held up by a handful of lawmakers.

Gov. Jay Nixon comments on Rep. Jay Barnes’ Medicaid bill, a possible alternative to increasing eligibility to 138 percent of the federal poverty level.

For his part, Nixon was in Kirkwood last Tuesday to drum up support for expanding Medicaid to 138 percent of the federal poverty. After his address, he told reporters that he was heartened that Barnes’ bill was a start of a serious discussion on the issue.

It’s “good that there’s movement forward in the House,” Nixon said. Barnes’ bill “will be a vehicle that can get this to the finish line. And that’s important. So I think it’s solid progress that people are working together to move the bill forward.”

Nixon cites other states’ compromise approaches
Asked about whether any proposal would have to expand Medicaid up to 138 percent of the federal poverty level, Nixon said, “138 percent is what the federal government says that it needs to have.”

“But there are lots of ways to get to 138,” Nixon said. “You could put some of these dollars through an exchange, for example, so folks would have a way to go on the marketplace. So the way Arkansas did it and the way some other states are doing it. So there’s lots of ways to get to 138 that aren’t necessarily just move Medicaid to 138.”

Nixon was referring to how the federal government gave the green light, so to speak, to Arkansas’ plan to expand health-care coverage to low-income residents through insurance exchanges as opposed to the Medicaid program.

Jones’ statement said, “Many states are looking to Arkansas to see what unfolds as they push for a system that would enroll those newly eligible for Medicaid into the same private insurance plans available to individuals and small businesses.”

That doesn’t mean Nixon is totally enamored with the proposal. In early March, he told reporters that he didn’t feel cutting children or pregnant women from the program were steps in the right direction.

“Do I have some issues with some portions of the bill? Yeah,” Nixon said last week. “But are we willing to work together? Absolutely. Will we work together to get reform? Yes. But the movement, the long hearing the House committee yesterday, the likelihood of that bill coming out of committee soon is a positive step for health care reform and Medicaid expansion.”

Jones went on to say at that many states are coming up with alternatives to Medicaid, adding “we’re going to have to come up with the Missouri solution.” That term — which was also used to describe a 2011 compromise on dog breeding legislation — was also brought up in Jones’ lengthy statement.

“As the president has seen more and more states refuse to accept federal dollars with all of the inflexible federal requirements, red tape and strings attached, we have seen a greater willingness to allow state governments the flexibility necessary to transform Medicaid as they see fit,” Jones’ statement said. “Our transformation plans will go nowhere unless the federal government agrees to let us develop the Missouri solution for Missouri’s Medicaid system,” he added.

Since Nixon announced his support for expanding Medicaid shortly after he was re-elected, the governor has spent the past few months traveling across the state to bolster his case on the issue.

His latest scheduled stop was Tuesday in Wentzville. Last week, he was at the Kirkwood Community Center to make his pitch.

Before he spoke, Nixon was introduced by St. Louis Regional Chamber President Joe Reagan – whose group is one of numerous chambers of commerce backing an expanded Medicaid. Just as he had before, Nixon said that expanding Medicaid would be an economic boon to the state by creating thousands of health-care jobs.

He also warned that failure to expand Medicaid could hurt the state’s hospitals since their reimbursement for uncompensated care is expected to go down in the next few years. That’s one reason the Missouri Hospital Association has come out strongly in favor of the proposal.

Above is part of Nixon’s speech in Kirkwood pushing for a Medicaid expansion.

The tail end of the governor’s speech included an emotional plea: Expanding Medicaid is morally right for people who are working at the lower-end of the pay scale.

“There are hundreds of thousands of working Missourians who don’t have one of those cards,” said Nixon, referring to a health insurance card. “And you know? I bet a bunch of them are doing really hard jobs. Like after this last snow, getting out there at night, making sure the streets are ready for the next day. Not just city workers, I’m sure they’re covered. Or the county workers. But you and I both know there are private folks out there that are working jobs for $9, $10 or $11 an hour with no insurance.

“And when they got home, maybe they broke an ankle or twisted something someplace,” he added. “And they have no health insurance card even though they work just as hard as anybody else in this room. Working Missourians. People making $9, $10, $11, $12 an hour on their way up. This provides them with the basic dignity and strength that health care and preventative health care can provide.”

Op ed reprinted from the St. Louis Post Dispatch, August 7, 2012    

By Ed Weisbart, M.D.

Nearly 300,000 more Missourians could soon get access to health care if Missouri state officials decide to provide it.

Unfortunately, recent comments by the state Legislature’s leadership cause us to believe that they seem poised to deprive Missourians of this basic human right.
We, members of the Consumers Council of Missouri, urge the public to consider this decision carefully and act in the best interest of our friends, families and neighbors. Missourians must insist that members of the House and Senate and Gov. Jay Nixon not tolerate avoidable human suffering. As stewards of health care for hundreds of thousand of poor Missourians, these state officials should increase the role of Medicaid in the manner spelled out by the Affordable Care Act.

It’s humane and compassionate and it makes economic sense for Missouri consumers.

The Missouri Foundation for Health recently determined that over the next five years, the ACA would pump $8 billion into Missouri to expand health care to the 300,000 people. The state would be responsible for only $400 million, a small amount in comparison. If policymakers are inclined to think that 5 percent responsibility is too steep for Missouri, they should appreciate that the $8 billion will primarily become taxable income for health care providers (that’s jobs, jobs, jobs). No matter how you do the math, it’s going to cost the state very little to save a bunch of lives and provide health care for hundreds of thousands of Missourians.

Compound that with the fact that each of us in Missouri already pays for the health care of these 300,000 uninsured members of our community. Who else pays when someone without insurance goes to a hospital with a heart attack or stroke? Long ago, we as a society decided that a hospital couldn’t turn away someone who is desperately ill. If the patient doesn’t pay, guess who does? Each of us. The hospital writes it off, but it does so by charging those of us who have insurance a bit more.

We need to take full advantage of the value the ACA brings to Missouri consumers, even though it is not the legislation we believe would benefit Americans the most. The biggest problem with the ACA is that it preserves the dominant role of the private insurance industry in health care. With private insurance involved, for every dollar spent in the health care system, 31 cents pays for administration, profits and overhead. Instead of paying for actual health care, our premium dollars pay for those employees whose job it is to tell policyholders that we can’t get the health care we need, or to call doctors to explain that a prescription the doctor wrote isn’t the insurance company’s “preferred” prescription.

The Consumers Council of Missouri believes that consumers would best be served by fixing Medicare and providing it to all Americans. The ACA failed to do that. But it was enacted with the promise that it would create affordable insurance coverage for roughly half of today’s uninsured Americans. And much of that happens by expanding Medicaid and requiring the states to pick up less than five percent of the tab.

By taking advantage of the ACA and providing health care to at least a portion of uninsured Missourians through the Medicaid expansion, the state would let the federal government purchase, for example, a bottle of pills to treat high blood pressure. Our state’s leaders appear to prefer to let patients suffer, get overwhelmed by a massive illness, declare bankruptcy and wind up costing each of us plenty more than it would cost to expand Medicaid under the ACA.

Where is the fiscal prudence in this strategy? Where is the justice for the consumers who are rationed out of health care? Where are the moral ethics that should guide our state’s political discussions? Where are the hearts and minds of anyone who could oppose providing the basic human right to health care?

We urge the members of the Legislature and the governor to choose access for more health care consumers in Missouri and financial prudence for the state coffers by expanding Medicaid under the ACA.
Tomorrow, improved Medicare for all. Today, let’s at least take full advantage of the law and save some lives.

Dr. Ed Weisbart is a board member of the Consumers Council of Missouri and chairman of Physicians for a National Health Program-St. Louis.