Republican senators resoundingly rejected a plan Wednesday to expand Missouri's Medicaid coverage to several hundred thousand lower-income adults as they began debate on legislation that instead would revamp the way the program is managed.
The Senate's 23-9 party-line vote marked the first official defeat of Medicaid expansion since Democratic Gov. Jay Nixon renewed his call for it during his State of the State address this year.
But the outcome was never in doubt.
The Republican-led Legislature repeatedly defeated Democratic attempts last year to expand Medicaid eligibility, and GOP leaders have strengthened their rhetoric against it since then - even while special interim committees studied ways of overhauling the program.
Missouri's Medicaid program currently covers about 850,000 people at an annual cost of nearly $9 billion, most of which comes from the federal government.
About half of the states have expanded Medicaid under the terms of President Barack Obama's health care law. States that do so can receive enhanced federal payments. Missouri could get about $1.7 billion next year from the federal government by expanding eligibility to about 300,000 people.
But in future years, states must gradually start picking up 10 percent of the expansion costs.
"We cannot afford it," said Senate Appropriations Committee Chairman Kurt Schaefer, R-Columbia, who argued that bigger Medicaid bills would mean less money available for education.
Nixon's administration contends the influx of federal dollars from a Medicaid expansion would help the state's finances. That's due partly to a projection of increased tax revenues and partly because some patients who currently are covered through higher-cost state programs could be shifted into the expanded Medicaid program.
Democratic Sen. Paul LeVota, who proposed the Medicaid expansion, said Republican colleagues are making excuses for not supporting it.
Expanding Medicaid is the "easiest and simplest way to improve our health care in our state (and) improve our economy," said LeVota, of Independence.
LeVota offered the Medicaid expansion as an amendment to a bill by Sen. David Sater, R-Cassville. That legislation would require the state to use managed care policies for most parents and children enrolled in Medicaid.
Such coverage currently is available in about half of Missouri, with medical providers in the rest of the state paid a set fee for each service they provide.
Some Republicans contend managed care would save the state money while improving patient access to medical professionals, though there is disagreement about that.
"With managed care we are using the private sector to run the Medicaid program," Sater said.
The Senate quit Thursday without voting on the managed care legislation.
LeVota's amendment would have expanded Medicaid eligibility to adults earning up to 138 percent of the poverty level - a little less than $33,000 annually for a family of four. Missouri's current eligibility cutoff is the lowest allowed under federal law - about $4,500 for that same family of four. Missouri only covers adults who have custody of children, are disabled or are seniors.
The Medicaid expansion was a key part of how Obama hoped to extend coverage to millions of uninsured Americans. State Medicaid programs were intended to pick up the lowest-income individuals while those living above the poverty level could receive subsidies for private insurance plans purchased through new online insurance marketplaces.
Missouri chose to let the federal government operate its health insurance exchange.
Since the health insurance website launched in October, Missouri has received the names of more than 25,000 people determined to be potentially eligible for Medicaid. But none of those people have been added to Missouri's Medicaid program yet.
Missouri officials say that's because the data from the federal government is not in a format that can be easily used and has errors, duplications and missing information.