By Jeff Fox

Two local state legislators who have been taking a longer look at proposals to expand Medicaid are expressing some optimism that the Missouri General Assembly will take action on the issue in 2014.

“It’s a tough issue. I think there’s a small window to get things done,” said Rep. Noel Torpey, R-Independence.

“It’s on the table,” said Sen. Paul LeVota, D-Independence.

Torpey for the last several weeks has led a 50-member group – the Citizens and Legislators Working Group on Medicaid Eligibility and Reform – that held hearings in a half a dozen cities, including Independence. In St. Louis, for example, 100 people testified, he said. Generally those at the hearings spoke in favor of expanding the program, for which the federal government is offering incentives under the Affordable Care Act, or Obamacare.

“It’s clear to me even the people who want expansion want reform,” Torpey said.

Gov. Jay Nixon pushed the General Assembly this year to take Washington’s offer: Broaden eligibility standards and add roughly 300,000 people to the nearly 900,000 Missourians currently on Medicaid. Generally only children, pregnant women and the disabled currently qualify in Missouri. Washington would pick up the full cost of expansion for the first three years, and the state would pick up 10 percent of that cost by 2020.

That would have meant an estimated $800 million a year coming into the state, advocates argued, greatly enhancing the financial stability of hospitals, especially in rural areas. Chambers of commerce across the state – including those in Independence and Blue Springs – endorsed the idea on the grounds of job retention at hospitals. The governor argued it was the right thing to do financially and morally, getting health-care coverage for those who often work one, two or even three low-wage jobs that lack health insurance. Those are the people who often turn to emergency rooms when a routine problem gets out of hand, and hospitals say uncompensated care like that drives up costs that eventually are passed on to everyone.

The Republican-controlled General Assembly did not act on the Democratic governor’s plan. About half of the states have expanded Medicaid. Among other things, legislators said they didn’t trust Washington to keep its word on funding over the long term. They also described Medicaid as a broken program that needs reforms before there’s any talk of expansion.

After legislators adjourned in May, both houses appointed committees to hold hearings on the issue and draft legislation. Torpey’s group is done, and now he will serve as vice chair of a second committee – all legislators this time – that meets this fall with the aim of writing a bill. LeVota has been on a similar Senate committee.

“You know, I think in the first hearing a strong case was made for expansion of Medicaid,” said LeVota, who fully supports the idea and sponsored the Senate bill to do that in the 2013 session.

Torpey has been more skeptical. The said the hospitals haven’t made a strong case yet, and earlier this year he rejected their claim, in a University of Missouri study, that expanding Medicaid would mean thousands of more jobs, including about 4,500 in the metro area.

Medicaid is mostly paid for by Washington but is run by the states. A handful of states, Torpey points out, have struck out in their own direction, with Washington’s approval, and he said Missouri should pursue that, too. One phrase that officials have used is that those on Medicaid should have “skin in the game,” that is, some financial incentive to help control costs overall.

“We should incentivize good behavior” such as healthier lifestyle choices, Torpey said.

One idea is health savings accounts. Another could be co-pays for non-emergency-room visits.

“That could make some sense, too,” LeVota said.

Torpey also says some current policies make no sense. Medicaid will pay for a knee replacement – but not the followup therapy.

“It’s things like that – you just shake your head,” he said.

Torpey also has been critical of the lack of transparency and clarity in hospital billing, and he suggests that could be part of reforms too. What is the cost of procedure X? It’s virtually impossible to find out, he says.

“I don’t know another field that you can do that in,” he said.

Significant changes to the program would require waivers from the federal government. “Let’s push the envelop on that,” Torpey said.

LeVota, agreeing there’s a concern that some changes might unacceptably water down the intent of Obamacare, favors a more conservative approach.

“We can’t design legislation on whether the federal government will act,” he said.

Both Torpey and LeVota said the dispute over House Bill 253 – an income-tax cut vetoed by the governor – could overshadow debates on issues such as Medicaid. The tax cut is a high priority for Republican legislators. Medicaid is a high priority for Nixon. Legislators plan to vote on overriding his veto in two weeks.

“It (the tax cut) really is one of those things that I haven’t seen such public engagement in awhile,” LeVota said.