Although he acknowledges his prospects are slim, a Republican senator is circulating a plan he says would use federal Medicaid dollars to expand Missouri's health care coverage to low-income adults without busting the state budget.
Sen. Ryan Silvey, of Kansas City, wants to use an influx of federal money to help finance private health insurance plans for low-income adults. He contends Missouri can set aside some of the savings it achieves in the initial years to help pay for the coverage in future years as federal funding is scaled back and the state's share increases.
"In my opinion, we are not doing "Medicaid expansion,'" Silvey said. "I call it an alternative to solve the problems created by the ACA," the federal health care law known as the Affordable Care Act.
Republican Sen. John Lamping, one of the state's most outspoken critics of the federal health care law, said Tuesday that Silvey's proposal appears to embrace President Barack Obama's agenda and thus still would encounter opposition.
"The idea that this is reform is a smoke screen to get the expansion" of Medicaid, said Lamping, of St. Louis County.
The Senate tussle over Medicaid illustrates at least two things. Supporters of expanded coverage have gained some allies among Republicans. But other GOP opponents remain as committed as ever to preventing any sort of Medicaid expansion from passing this year.
Silvey acknowledges there's only "a slim possibility" his proposal will pass this year and the discussion may carry over into next year. But he nonetheless has been meeting with individual senators and has put together a three-page outline of a potential health care expansion that incorporates his proposed financial safeguards and pairs Medicaid changes with additional work requirements for enrollees in other welfare programs.
Silvey is a former Missouri House Budget Committee chairman who earlier in his career served as a legislative aide to former Republican U.S. Sen Kit Bond, of Missouri. Bond has been hired as a lobbyist by the Missouri Chamber of Commerce and Industry to persuade Republicans to accept a Medicaid overhaul. His consulting firm is promoting Silvey's proposal.
Under Obama's health care law, states that expand adult Medicaid eligibility to those earning up to 138 percent of the poverty level - nearly $33,000 annually for a family of four - can initially receive full federal funding for that group. The federal share gradually would be scaled back to 90
percent funding - still significantly more than Missouri receives for most Medicaid expenses.
Democratic Gov. Jay Nixon, who supports Medicaid expansion, has estimated Missouri could save money by switching some people whose health care is covered by state funds into the new federally funded Medicaid category.
Silvey said those initial savings could be stockpiled to help cover the state's future costs. If that doesn't provide enough money, Silvey said future state costs could be covered by reducing the state's reimbursement rate to hospitals.
He proposes to provide Medicaid coverage through managed care insurance policies for adults living in poverty, with premiums required for the top half of that group. The premiums could be waived if people meet healthy behavior goals. For those earning above poverty, the state would use federal Medicaid money to subsidize private insurance plans purchased through a federally run online marketplace. A similar approach is being pursued in some other states with Republican-led Legislatures.
A Missouri House committee also has heard testimony on a similar proposal. But committee chairman Rep. Jay Barnes, R-Jefferson City, said he has no timetable for holding a vote on the legislation.
Silvey could try to amend his proposal to a separate bill pending in the Senate that, as currently written, would require greater use of managed care policies in Medicaid but would not expand eligibility to the levels set under the federal health care law.
"If someone wants to put Medicaid expansion on there, I don't believe the votes are there" to pass it, said Senate Majority Leader Ron Richard, R-Joplin.