Supporters of Medicaid expansion in Missouri continue to work on swaying opponents in the General Assembly over to their side. While it appears they have a long way to go, and the clock is ticking on the legislative session, some key advocates say they may be close to turning the tide, at least when it comes to a scaled-back expansion that would be paired with reforms.

“We’ve had a lot of discussions with a lot of legislative leaders and have been pleased with the outcome of some of those discussions,” said Brendan Cossette, director of legislative affairs with the Missouri Chamber of Commerce and Industry. “Just because you (read) something in the paper or you…hear something on the radio, there might be a lot more going on behind the scenes, and I’m optimistic that we’ll have a pretty good shot of getting something done this year.”

Cossette, however, did not identify which legislative leaders from whom he’s had positive feedback. And despite his optimism, Cossette said that if he knew exactly what his chances for success on Medicaid expansion were, he’d “be in (Las) Vegas right now.”

Meanwhile, the Missouri Chamber has teamed up with the Missouri Hospital Association to campaign for Medicaid expansion. They released a survey last month showing that hospitals in Missouri eliminated nearly 1,000 jobs over a six-month period, that hiring freezes have left over 2,100 vacancies unfilled, and more than $100 million in hospital construction and renovation projects have either been canceled or delayed. The chamber’s CEO, Dan Mehan, says the figures will only get worse if Medicaid is not expanded.

“This is a problem, it’s not going away,” Mehan said. “If people want to stick their head in the sand and pretend that it’s going to solve itself or that we don’t have to do anything, we think that’s the wrong attitude to take.”

Near the mid-point of last year’s legislative session, the Missouri Chamber announced its support for expanding Medicaid, saying that its "hands had been tied by Obamacare.” The chamber and the hospital association both cited last year’s provision in the 2010 Affordable Care Act in which the Disproportionate Share Hospital program, or DSH payments, were to be phased out. The program provides federal dollars to hospitals to cover the cost of treating indigent patients.

The federal health-care law was originally written to require all states to expand Medicaid to cover the DSH phase-out to hospitals, but the U.S. Supreme Court ruling that upheld Obamacare also struck down the mandatory Medicaid expansion. The result: Rural hospitals in Missouri — and elsewhere — were put into the position of depending on Medicaid expansion to continue receiving federal aid to treat the indigent.

The Missouri Chamber made a splash earlier this year when it hired the high-profile Republican, Kit Bond, a former governor and U.S. senator, to lobby the legislature on behalf of Medicaid expansion.

Bond began preaching a message that Missouri needed to craft its own Medicaid solution that included both reforms and expansion. He said Missouri needs to accept more Medicaid dollars because Obamacare has been a “disaster.” He specifically cited the eventual cancellation of federal DSH payments to rural hospitals.

“I’m concerned that hospitals in rural and inner-city communities will be forced to make dramatic cuts in their services and in some cases close their doors,” Bond said at a Missouri Chamber function Feb. 25.

It’s also noteworthy that Bond used the words “reform” and “transformation” to define his Medicaid proposal, not “expansion.”

“We want everyone in Missouri to understand that ‘Medicaid transformation’ doesn’t expand MOHealthNet,” Bond told reporters. “It (would take) federal money that’s going to be coming into the state…(and would put) people in private sector health-care programs that will be managed by more efficient privately run entities.”

Bond also told reporters that day that he was personally contacting Republican lawmakers and felt confident that enough of them would eventually support and pass a reform package with some Medicaid expansion. But that was nearly a month before five fellow Republicans in the state Senate made their vow to block expansion.

Who is eligible for Medicaid?

Tim Bommel, Mo. House Communications

Right now, Missouri currently provides Medicaid coverage only to adults who earn no more than 19 percent of the federal poverty level or $2,217 a year.

Gov. Jay Nixon, a Democrat, has called for expanding Medicaid up to 138 percent of the poverty level because that is the level required by the federal government to be eligible for the federal match. Under the Affordable Care Act, the federal government pays all the expansion costs for the first three years and at least 90 percent thereafter.

Governor Nixon is continuing his efforts as well to put public pressure on legislative leaders to expand Medicaid. He has traveled around the state this year, including stops this week in Rolla and Sedalia, where he's called on citizens to tell their legislators to support Medicaid expansion. The governor also used April 15th to unveil a new webpage on the state's official website, mo.gov/WePaidForIt. It contains an interactive map that shows estimates of how much money other states are getting from the federal government because Missouri has not expanded Medicaid. Nixon contends that the state is losing $5.47 million a day, roughly $2 billion a year, in federal Medicaid dollars.

The Republican-backed Medicaid "transformation" bill

Meanwhile, only one bill encompasses the so-called alternative plan to Nixon’s call for expanding Medicaid. House Bill 1901, sponsored by state Rep. Noel Torpey, R-Independence, is almost identical to a House bill last year sponsored by state Rep. Jay Barnes, R-Jefferson City. Barnes is co-sponsoring Torpey’s bill this year. Specifically, it would:

provide Medicaid coverage to working Missourians whose incomes fall below 100 percent of the federal poverty level.

allow those whose incomes fall between 100 and 138 percent of the federal poverty level to purchase health coverage from private companies through the federal health exchange. That’s the expansion part of Torpey’s bill.

Torpey’s bill would also put restrictions on recipients: They must be employed; they must not rely on emergency rooms for primary care; and would-be recipients found guilty of a crime involving alcohol or drugs would have to be assessed by the Department of Mental Health before receiving services.

Hospitals would also have to be more transparent in how much they charge patients for various services, and those that fail to accurately disclose those costs could face fines.

Torpey’s bill would also require waivers from the federal government for it to take effect, which at this point doesn’t appear likely. At an appearance in St. Louis in January, Health and Human Services Secretary Kathleen Sebelius indicated that waivers would only be considered if a state were to expand Medicaid coverage to people earning up to 133 percent of the federal poverty level. Torpey’s bill would only expand Medicaid coverage to people making up to 100 percent.

Hearings on the bill are currently on hold and so far there’s no indication on when they will resume. House Speaker Tim Jones, R-Eureka, and budget chairman Rick Stream, R-Kirkwood, have been adamant that a bill will not get a House vote. They and other GOP lawmakers contend that Missouri will not be able to afford the 10 percent cost share that would eventually take effect.

House Minority Leader Jake Hummel, D-St. Louis, has maintained that a majority of the House’s members would vote for Medicaid expansion should it come up on the House floor.

Senate's Medicaid proposal

Mo. Senate

Meanwhile, another Republican-backed Medicaid expansion proposal waits to be introduced in the Missouri Senate. It’s too late in the session to craft the proposal as a bill, but it’s possible that it could be amended on to another Senate bill with a similar subject matter.

The Senate proposal is similar to the bill in the House: It would provide coverage for those below the poverty level through a managed care plan, and those between the poverty level and 138 percent would receive coverage through the federal exchange.

It would also require waivers from the federal government, and it includes many of the same reforms laid out in the House bill.

The Senate version, sponsored by state Sen. Ryan Silvey, R-Kansas City, goes further, in that it would also address Missouri’s food stamp program, requiring EBT cards to have photo IDs and requiring food stamp recipients to be employed or enrolled in college.

“I feel like if we’re going to tackle this problem of welfare and how it’s administered in the state of Missouri, we ought to reform it all at the same time,” Silvey said.

Silvey has a hard sell, as indicated by a heated exchange he had two weeks ago on the Senate floor with state Sen. John Lamping,R-Ladue.

Lamping questioned Silvey’s conservative credentials for supporting any form of Medicaid expansion and called reform efforts a pathway to more big government.

“It’s time for you to take a hard stand and say ‘no,’ Lamping told Silvey on the Senate floor April 2. “You’re taking the pragmatic stand, the easy stand … how hard is it to spend federal money?”

Silvey fired back, “Whoa! It’s easy? It’s easy for me to stand up in a Republican Party with people like yourself who’d rather talk about sound bites and Obamacare than the actual problems that Obamacare has created?”

Last month, Lamping and four other Republican Senators vowed to block any and all forms of Medicaid expansion in their chamber. Silvey later admitted that his proposal’s chances are slim.

“My hope is that we can get past the rhetoric and get to the solution because the reality is the federal government has created a mess for us,” Silvey said. “I may not like the mess, but I kind of feel like it’s our job as a legislature to fix the mess, and hopefully I can get my colleagues there.”

Follow Marshall Griffin on Twitter: @MarshallGReport