As a Democratic candidate for governor, Jay Nixon pledged to expand Medicaid coverage as his "first order of businesses."
During his first year as governor, he failed to persuade the Republican-led Legislature to pass a relatively moderate Medicaid expansion.
Now up for re-election, Nixon is refusing to take a position on whether Missouri should embrace a comparatively larger Medicaid expansion called for under President Barack Obama's health care law.
What's changed?
Does Nixon no longer believe in expanding Medicaid health coverage? Or have political realities tempered his rhetoric?
The answer may rest in the latter.
Nixon appears to have become more measured, less apt to make off-the-cuff remarks and less likely to take ambitious or controversial positions the longer he has served as governor.
"He's savvy," said George Connor, head of the political science department at Missouri State University. "He's very strategic in his decision-making."
When Nixon was running for governor, the 2005 Medicaid cuts of then-Republican Gov. Matt Blunt were still fresh in mind. About 100,000 low-income adults had been dropped from Missouri's Medicaid rolls and benefits had been pared back for about 300,000 others.
Nixon held news conferences across the state in July 2008, declaring: "Missouri's health care system is broken." He pledged to restore health care to those who lost it. Specifically, Nixon said Missouri could draw down $431 million from the federal government by spending an additional $265 million of state money to expand Medicaid coverage to 109,811 people and restore benefits to an additional 280,000.
"Missouri simply cannot afford to leave those federal dollars on the table," Nixon's 2008 platform book stated.
Nixon could make the same argument about Obama's health care law, which offers states an even better federal matching rate if they raise Medicaid eligibility for working-age adults to 133 percent of the federal poverty level. But Nixon so far has not done so.
The federal government would pay 100 percent of the cost for the Medicaid expansion beginning in 2014. In 2017, states would have to pick up 5 percent of the tab - a share that would increase annually until topping out at 10 percent. In 2019, the latest year for which Missouri has released projections, the state would pay more than $150 million while getting $2 billion from the federal government for a Medicaid expansion covering 255,000 adults.
After the U.S. Supreme Court ruled that states could not be penalized with the loss of their existing federal Medicaid dollars for refusing to go along with Obama's Medicaid expansion, Missouri's Republican legislative leaders were quick to say that they would reject it. They cited concerns about whether Missouri could afford its share of the cost. Some Republicans also expressed reservations about expanding social welfare programs. By contrast, some Democrats said it would be foolish for Missouri to turn away such a lucrative offer of federal cash that could improve the health care of so many people.
Nixon said virtually nothing.
During a Capitol news conference this past week, Nixon went to great lengths to avoid saying "yes" or "no" to repeated questions about whether he supports the Medicaid expansion. Instead, Nixon said five times during five minutes that he would work for "the best fit for our state."
Nixon vowed to work with "legislators," "folks," "stakeholders," "hospitals," "others" and "everyone around the table." He said he wants "the best health of the folks of our state," to use "taxpayer dollars efficiently and effectively" and to "keep the sovereignty of the state."
"It's really easy to just say "yes' and "no' and to start this kind of banter back and forth that Washington has become so famous for," Nixon said. "Quite frankly, I'm not going to do that. I'm going to work with folks. Whatever gets done is going to require all of us coming together."
That kind of response has come to define Nixon's term as governor. As a Democratic chief executive working with historically large Republican legislative majorities, Nixon cannot practically - nor politically - undertake too many initiatives for which he does not have Republican support. In fact, there are times when Nixon sounds more Republican than some actual Republicans. He touts cutting more than $1.8 billion of spending and 4,000 state employee positions since taking office in January 2009. And while Democrats in some states sought new taxes to balance their budgets during the recession, Nixon joined Missouri Republicans in taking a firm anti-tax stance. Just this past week, he vetoed a bill passed by the Legislature with bipartisan support because he said it would authorize a new tax without a vote of the people.
In a mere four years since Nixon last ran for office, Missouri has become more ideologically conservative, and "Governor Nixon has been pretty good at riding that wave," Connor said. He added: "That moderation is as much calculated as it is ideological."