A political battle looms between Democratic Gov. Jay Nixon and the Republican-dominated General Assembly over whether to add 300,000 uninsured Missourians to the public health insurance program for the poor.
After avoiding taking a position for months, Nixon ended his silence on that issue Thursday by formally calling on Missouri lawmakers to expand Medicaid in line with the federal Affordable Care Act, sometimes known as Obamacare.
"If we do this correctly, we'll improve the health and quality of life for hundreds of thousands of Missourians and transform the expensive and scattershot way we now provide care for people without health insurance," Nixon said.
The stance puts the Democratic governor at odds with Republican legislators who have made it no secret over the years how much they despise President Barack Obama's health care law and oppose implementing any of its provisions.
And it sets the stage for a showdown between a governor who just won a second term by a wide margin and a Republican Party that has supermajorities in both the House and Senate.
"The state of Missouri is not going to expand Medicaid in the fashion contemplated by Obamacare," Rep. Jay Barnes, a Jefferson City Republican, said earlier this month. "That's not happening."
Nixon contends that Missouri can't afford to turn down billions in federal funding, and he has the support of a diverse coalition of groups ranging from organized labor unions to the Missouri Chamber of Commerce.
"If we take a pass on billions of health care dollars -- dollars that come out of Missourians' paychecks -- that money will go to some other states," Nixon said. "They'll get the benefit, and we'll get the bill."
The federal government would pay 100 percent of the additional cost initially, with states picking up 5 percent beginning in 2017 and 10 percent by 2020.
A report released Wednesday by the Missouri Hospital Association and the Missouri Foundation for Health estimates that Missouri Medicaid expansion would cost the federal government $8.2 billion and the state $333 million between 2014 and 2020.
But even a small increase in Medicaid expenditures is too much, said House Speaker Tim Jones, a Eureka Republican.
"My first question to the governor is this: Where is the money to pay for this once the federal aid goes away?" Jones said. "The federal government is providing the funding now, but it is likely to disappear in just a few years as our nation comes to grips with our crippling national debt."
Proponents of expansion argue that some of the costs would be offset by savings in other areas of the budget, such as money the state spends on health care for people who would probably be covered under expanded Medicaid.
The Missouri Hospital Association study also contends that the additional federal money could lead to 24,000 new jobs across the state in 2014 alone.
Nixon embraced those figures Thursday, arguing it is time for Republicans to put aside their opposition to the federal health care law and work toward the best solution for Missouri.
"Congress passed it, the president signed it and the Supreme Court upheld it. It is the law of the land," Nixon said.
"I just don't see this as a Republican-Democrat issue. It's not politics. It is just common sense."
Another factor, Nixon said, is the financial hit hospitals around the state will face if Missouri does nothing. A provision in the federal health care law phases out payments to hospitals for treating the uninsured on the assumption that more people will have coverage either through private insurance or Medicaid.
The Missouri Hospital Association has warned that losing payments without increasing the number of insured could create a situation where many hospitals are forced to close their doors, especially those in rural areas.
Jones said he shares the concerns of Missouri hospitals but that still doesn't justify an expansion.
"I'm not going to deny that we are likely facing a health care fiscal cliff in our state," Jones said. "I don't think you automatically just have the knee-jerk response that we should just expand Medicaid and get all that free money. As we all know, it's not free money.
"Long term, it just puts the state on the hook and in the position of having to make cuts in other programs," Jones said, pointing specifically at education, transportation and public safety.
Republicans also have argued that if enough states refuse to accept Medicaid expansion, the federal government will have no choice but to rework the program.
"The governors of eight other states have recognized this and confirmed they will not take part in the expansion of Medicaid, and I think Missouri should join them, not embrace the Obama agenda," Jones said.
Nixon said he will "work tirelessly" to convince skeptical lawmakers. On Thursday, he trumpeted his support of Medicaid expansion at events at medical centers in Kansas City, St. Louis and Springfield.
The governor will formally unveil his proposed budget during his State of the State address in January.