Gov. Jay Nixon and other officials say the future of Missouri’s hospitals and the health of hundreds of thousands of Missourians are on the line as state leaders decide whether to expand Medicaid, as envisioned under federal health-care reform.

Gov. Jay Nixon and other officials say the future of Missouri’s hospitals and the health of hundreds of thousands of Missourians are on the line as state leaders decide whether to expand Medicaid, as envisioned under federal health-care reform.

Gov. Nixon came out in favor of the plan Thursday.

“It is the smart thing to do, and it’s the right thing to do,” he said.

He said he’ll push for the idea when legislators convene in January.

Republican leaders, who have solid majorities in both houses of the Missouri General Assembly, again flatly rejected the idea.

“I have grave concerns about the affordability of it,” Senate Appropriations Committee Chairman Kurt Schaefer, R-Columbia, told the Associated Press.

Nixon said the state can manage that.

“We can and we will maintain our fiscal discipline throughout this process,” he said.

Nixon said the move would bring health insurance to about 300,000 Missourians who currently lack it, would create thousands of jobs and would get hospitals across the state out of a financial vise created by the rising costs of uncompensated care but falling federal money to help offset those costs.

Across the state, he said, there are “too many folks who have to choose between paying for food and paying for medicine. We can do better by them, and we will.”

Elected officials and health-care executive are trying to balance changing rules under Obamacare. The background – locally, statewide and nationally – looks like this:

One of the ways the Patient Protection and Affordable Care Act – Obamacare – is designed to improve health care is to expand Medicaid, which is health insurance for the poor. It’s mostly paid for by the federal government but run by the states, each with its own rules. About 900,000 Missourians are on Medicaid. Under Obamacare as Congress passed it, states were compelled to expand Medicaid or lose their federal funding.

The Supreme Court in June upheld Obamacare – “It is the law of the land,” Nixon said Thursday – but separately the court took away Washington’s fiscal stick. States can expand Medicaid or not, but still not lose the federal money.

For hospitals, that creates a huge catch. By law, they are obliged to provide care for those who show up in their emergency rooms – racking up bills on which they often cannot collect. Officials also point out that, in addition to the added human suffering when treatment is delayed, waiting until an ER visit is needed sharply raises the cost of treatment.

“Typically these are hard-working people. They work in low-wage jobs or work for small businesses that can’t afford health insurance,” said Charlie Shields, chief operating officer at Truman Medical Center-Lakewood, which sees a large number of patients from Eastern Jackson County.

For example, Truman Medical Center’s two campuses at Lakewood and Hospital Hill provide $128 million in uncompensated care annually – 11 percent of all such care in the state.

“Uncompensated care continues to go up. ... We continue to take those hits,” John W. Bluford, TMC’s president and CEO said earlier this week.

The federal government currently puts up some money to help hospitals with that, but part of Obamacare is phasing out that money in a few years under the theory that just about everyone – including those brought into an expanded Medicaid program – would have health insurance.

With that money going away but no new money coming in via Medicaid, “these hospitals are in the soup,” Nixon said, adding that many hospitals across the state would be in danger of closing.

“I think it would be devastating to Truman Medical Centers,” Bluford said.

Jackson County subsidizes TMC with about $11.5 million a year, and Kansas City gives about $28 million, but Shields said TMC would not likely ask those sources for more money.

So after the Supreme Court decision, Washington is offering states this deal: Beginning Jan. 1, 2014, expand Medicaid to a certain level – those at or below 138 percent of the federal poverty level – and we’ll pick up the full cost of those added people at first. For reference, in 2011, the federal poverty level was $18,530 for a family of three.

Washington would pay the full cost only for 2014, 2015 and 2016.

“That’s why we need to go forward now,” Nixon said.

In 2017, that federal share drops to 95 percent, then a little less in 2018 and 2019, settling permanently at 90 percent in 2020.

For Missouri, that means an estimated state cost of $400 million through 2020, bringing in $8.3 billion in federal dollars flowing to doctors and hospitals across the state.

“It’s a heck of a deal,” Bluford said.

Republicans said the cost of Nixon’s plan is more than either the deficit-plagued federal government or the budget-crunched state government should be spending.

“It’s a massive expansion of a welfare program” that he said could reduce the money available for other priorities such as public schools, Sen. Schaefer told the AP.

Republican Lt. Gov. Peter Kinder, who has challenged the federal health care law in court, accused Nixon of trying to “hoodwink the voters” by waiting until after the election to announce his support for the Medicaid expansion. He called it “a radical, unaffordable agenda that will break the bank in Missouri.”

But Nixon underscored the point that Missourians pay federal taxes and that other states will get federal money by expanding Medicaid even if Missouri does not.

“They’ll get the benefit, we’ll get the bill,” he said. “That’s not smart, and it’s not right.”

Officials also say there is a strong business case for expanding Medicaid – an added 24,000 jobs in 2014 alone, including 4,236 in Jackson and four other metro area counties, according to a Missouri Hospital Association study.

Also, advocates argue, the move would ease pressure on private health insurance premiums be curtailing cost-shifting.

“The cost of uncompensated care is borne by businesses that provide health insurance for their employees,” Shields said.

“It (expansion of Medicaid) protects Missouri businesses,” he said. “It protects Missouri jobs.”

Associated Press reporter David A. Lieb contributed to this article.