Just a few weeks after the Missouri General Assembly got underway in January, state Rep. Noel Torpey conceded the difficulty of getting major changes he sought for the state’s Medicaid program.

“ ... I really believe we need to put the politics aside and look at policy,” Torpey said in February.

Legislators adjourned last month and once again without acting on a proposal by Gov. Jay Nixon to expand the program, adding coverage for about 300,000 people – including 40,000 in Jackson County – despite pleas from hospital and business groups around the state. Advocates say refusing to expand the program along the lines that the federal government wants is not only denying working people health coverage but is hammering hospitals financially.

Torpey’s bill to restructure the program, add recipients and accept federal money to pay it – as about half of the states have done – got out of a House committee but no further this year.

“Certain people can’t get around the fact that it’s the Affordable Care Act,” he said at last Friday’s legislative briefing sponsored by the Independence Chamber of Commerce.

When the U.S. Supreme Court upheld the Affordable Care Act, or Obamacare, two years ago, it also issued a second major ruling: The federal government could not compel states to expand Medicaid, as envisioned under the ACA. Instead, Washington would have to rely on incentives. It’s offering to pay the full cost of new enrollees for a few years and then taper back to 90 percent by the end of the decade. That would have meant $900 million for Missouri this year, according to Nixon.

“And it’s the fiscally right thing to do in Missouri,” Torpey said.

But as Torpey outlined it Friday, the politics of Medicaid in Missouri are straightforward. Three years ago legislators voted on health exchanges, also part of Obamacare and the means by which millions of Americans since have bought health insurance.

In the Missouri House, four representatives who voted for that subsequently lost races for the Senate.

“They lost on that vote and that vote alone,” Torpey said.

Legislators considering upcoming elections haven’t forgotten the risks of being portrayed as supporting the ACA.

“And it’s effective in campaigns, unfortunately,” Torpey said.

During Friday’s update, a state representative from the other side of the aisle singled out Torpey for praise for pushing the issue. Rep. Tom McDonald, D-Raytown, said Torpey has worked hard and against long odds within his own party. “He has been the only voice” among Republicans for expansion, McDonald said, and he suggested history will one day look kindly on that.

Jobs but no coverage

Medicaid is largest public health program for the poor. The federal government picks up most of the costs, but the states run their own programs. In Missouri, it’s called MO HealthNet and covers about 800,000 people, generally children and pregnant women. That’s about one in seven Missourians. MO HealthNet pays for about half of the births in the state.

Torpey and others point out that 74 percent of the Missourians who get Medicaid have jobs – often two or three – but generally low-paying jobs without health benefits. Washington wants to raise the income limits so some working adults without children also would be eligible. That would add close to 300,000 people.

The idea behind Obamacare is that middle-income people without health care could buy it though the health exchanges – with federal subsides in many cases – and expanded Medicaid would cover virtually everyone else. Without that expansion, however, a Missouri family of four, with a household income of up to $94,000, is eligible for subsidies but a Missouri family making $20,000 is eligible for nothing.

Torpey’s plan – and he stresses reform ahead of expansion – is to expand Medicaid but make changes to save money and add requirements such as recipients generally having to work or be looking for work. He calls it a move in the right direction.

“If you really don’t like the Affordable Care Act, this makes it a little better,” he said.

Despite the politics of not wanting to be seen as embracing Obamacare, the General Assembly has taken one-at-a-time steps to do some of the things Medicaid expansion would accomplish. It acted to get rid of waiting lists for the CHIPS program for children, and a major metro area clinic will now be able to take Medicaid patients.

“The problem is we’re not drawing down the federal dollars like we should,” Torpey said.

Last summer Torpey led a House committee that met all over the state to hear from people about the issue and recommend legislation. State Rep. John Mayfield, D-Independence, also was on that committee.

Asked about it Friday, Torpey said there’s no need for a similar process this year.

“I think the issues have been vetted,” he said, “and we know what we need to do.”