While Gov. Jay Nixon and Republican legislative leaders quarrel over whether to expand the public health insurance program for the poor, one GOP state senator is proposing to cut some people off the coverage.
Sen. Rob Schaaf, a St. Joseph Republican, wants to roll back Medicaid eligibility standards for pregnant women and young children.
That savings, Schaaf said, would be used to expand eligibility for elderly, disabled and blind Missourians.
"I'm trying to make sure coverage goes to those who really need it the most," Schaaf said. "We try to cover too many people, so we do a bad job of taking care of those that really need it."
Schaaf, whose proposals are included in a bill he has introduced, envisions that those who would lose coverage could turn to subsidies included in the federal health care law. Parts of that reform take effect in 2014 to help pay for insurance purchased through health care exchanges.
That would save the state money because the federal government pays the entire cost of the subsidies. With Medicaid, on the other hand, states share in the costs.
"I'm not trying to hurt anyone," Schaaf said. "Tax credits can help those who lose Medicaid coverage, and the state can dedicate its resources to those who are unable to help themselves."
Critics of the idea worry the move could leave many without affordable health insurance and ultimately increase health care costs overall.
"Rather than expanding Medicaid so that both Missourians and the state can benefit, he's playing on the margins with the health of some of Missouri's most vulnerable populations," said Traci Gleason, director of communications for the liberal Missouri Budget Project.
Pregnant women are currently eligible for Medicaid in Missouri during their pregnancy and postpartum if they earn less than 185 percent of the federal poverty level, or roughly $34,000 for a family of three.
Schaaf's legislation would restrict eligibility to pregnant women earning less than 133 percent of the poverty level, or roughly $25,000 for a three-person family.
He would use any savings to raise the income threshold for the aged, blind and disabled. Today, they qualify if their income is 85 percent of the poverty level.
"Those people are unable to help themselves," Schaaf said. "The people who are working, they can help themselves. They can work harder. They can supplement their income in various ways."
The intent of the federal health care law, known as the Affordable Care Act, was for states to expand Medicaid to include all adults earning up to 138 percent of the poverty level.
Currently, Missouri excludes adults without children from coverage completely. Adults with children are only covered if they earn less than 19 percent of the federal poverty limit, or about $2,874 a year for a single parent with one child.
In June, the U.S. Supreme Court granted states the ability to refuse to expand their programs. Since then, Republican lawmakers in Missouri have balked at the idea, while Nixon, a Democrat, has said he would include the expansion in his budget.
Schaaf said he doesn't expect expansion to get much traction in the Republican-dominated General Assembly. Even if it does, he would be willing to help block it in the Senate.
"I can't imagine the expansion will pass," he said. "It's not on the table."
His sentiment has been echoed by House Speaker Tim Jones, a Eureka Republican. Senate President Pro Tem Tom Dempsey, a St. Charles Republican, said earlier this year that it's "very unlikely" that GOP lawmakers would approve a plan that encourages "an ever-expansive federal government."
Schaaf said he could support a targeted expansion that just focuses on elderly, disabled and blind Missourians, but the federal government has been clear that "we can't pick and choose."
"So since the federal government is going to offer subsidies," he said, "let's take advantage of them."
Beginning in 2014, tax credits will be available to help anyone earning less than 400 percent of the poverty level purchase insurance through the new health exchanges. To get a tax credit, however, individuals cannot be eligible for public coverage -- including Medicaid, Medicare or military coverage -- and must not have access to an affordable insurance plan through an employer.
Some are concerned, however, that what the government defines as "affordable" may leave some low-income Americans without coverage.
A recent analysis by the Congressional Budget Office concluded that two-thirds of those who would qualify for Medicaid under an expansion, but who live in states that reject the expansion, would not be eligible for a federal subsidy to buy private insurance. Those who do qualify for a subsidy will have to pay a portion of the exchange premiums themselves, the CBO report said.
For Gleason, whose organization supports the full expansion of Medicaid in Missouri, Schaaf's plan is "completely unnecessary. ... The expansion would benefit the people he is interested in most helping without harm to other Missourians."
Additionally, Schaaf's idea isn't fiscally sound, she said.
"Reducing the eligibility of children and families is likely to result in more premature births and chronic illness, which would be much more expensive for Missouri in the long run," she said. "It's an inefficient use of taxpayers' money."
Another potential roadblock to Schaaf's idea is a lawsuit filed by Oklahoma's attorney general challenging the federal tax credits. The suit argues that only state-run health care exchanges may offer subsidies to consumers. In states such as Missouri that have opted for a federally run exchange, the suit contends, those subsidies cannot be offered.
Schaaf's legislation would only go into effect if the subsidies were available.