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JEFFERSON CITY • Missouri’s Republican-controlled Legislature eschewed Medicaid expansion this session, but supporters are holding out hope for next year.

“We all know that we need to expand Medicaid. Everyone knows that,” said Sen. Jamilah Nasheed, a St. Louis Democrat. “This will save many lives, and I am optimistic that the right thing will be done.”

Republican legislative leaders have taken recent actions that appear to hint toward movement on the issue in the coming months. They also have expressed optimism over the potential to reform the health care program for the poor, using the expansion as a launch pad.

House Speaker Tim Jones, R-Eureka, and Senate President Pro Tem Tom Dempsey, R-St. Charles, have each created a panel that will study Medicaid reform and draft legislation for the 2014 session.

“I’m happy to talk about reform. If that helps draw down some additional federal funding and provide people more access to quality care, I’m all for that,” Jones said at a recent event in Columbia.

The federal Affordable Care Act encourages states to expand eligibility requirements to cover more people, but the decision is left to the Legislature to decide. If states agree, the federal government will pick up most of the costs.

Gov. Jay Nixon, a Democrat, lobbied hard for the plan, which would add an estimated 260,000 Missourians to the Medicaid rolls, but the proposal was repeatedly shot down when Democrats brought it up in the Legislature in the session that ended last month. Opponents argued that the move would eventually cost the state millions, that the federal government was an unreliable partner in the venture and that the expansion would add to the federal debt.

But Republican lawmakers for years have expressed interest in retooling Missouri’s Medicaid program to add more market-based components, claiming that the current system is inefficient and plagued with fraud, abuse and waste.

“We want to have a program that has a free-market flavor to it,” said Sen. Gary Romine, a Republican from Farmington who has been picked to lead the Senate Committee on Medicaid Transformation and Reform. “The program we have is just ineffective.”

Romine said he believes the state has “the greatest opportunity in our history to reform health care in Missouri.” He said it is also an opportunity to ensure that state officials navigate the future of health care here, rather than ceding to the federal government on the issue.

“It’s an opportunity we should take,” he said.

Romine said his goal is to have Medicaid reform legislation introduced on the first day of session and among the first bills sent to the governor.

“I feel like we’re a bit behind so we’ll have to work harder this summer,” he said. “We’re on the clock, as far as the fed government is concerned, so we’ve got to make some strong efforts right now.”

Rep. Jay Barnes, a Republican from Jefferson City who is heading the House counterpart committee, proposed a Medicaid reform bill this session that didn’t make it out of the House.

Both he and Romine pointed to that bill as something similar to what likely will be proposed in the Legislature next year.

“I think there’s a decent shot at giving Missouri the most market-based system in the entire country,” Barnes said. “It may not look exactly like (this year’s bill), but I think we’ll be looking for something in the same neighborhood.”

The reform elements of Barnes’ proposal included a shift to private managed care systems, an added push toward preventive care and financial incentives for recipients to keep their health care costs low. Several parts of his plan would require approval from the federal government.

Romine called Barnes’ plan a “good foundation for what we’re looking for.”

“Hopefully, between the two chambers working at it, we can create a great reform for the state,” he said.

Democrats have widely embraced the reform angle.

Nasheed said she particularly likes the efforts to inject personal responsibility into the system.

“Everyone has to take responsibility for their own life,” she said.

In promoting the expansion, the governor also has often noted the opportunity for reforms that would protect taxpayer dollars and enhance the quality of the program.

Nixon, who is term limited and can’t seek re-election, has staked significant political capital on the issue this year, making frequent appearances across the state to drum up support. He has continued to highlight the diverse coalition of health care providers, business leaders, clergy and others backing the plan.

But critics say he started the process too late for the often slow-moving Legislature to tackle the issue this year.

During his re-election bid last year, Nixon avoided taking a position on Medicaid expansion, which was made optional by a U.S. Supreme Court ruling last June. Three weeks after winning the election, the governor announced his support for it, calling expansion “the smart thing to do, and the right thing to do.”

Republicans and Democrats say the governor left legislative leaders with little time to react or start building a message in support of expanding Medicaid, which is intrinsically tied to the often-criticized federal health care law.

“The issue that some Republicans were having is that — without (Nixon) coming out front and expressing his support early on – they believe there’s politics being played,” Nasheed said.

Missouri’s Republican legislative leaders have been ardent opponents of the Affordable Care Act and President Barack Obama’s administration. They have pointed at ballot measures like 2010’s Health Care Freedom Act, which voters approved with more than 70 percent of the vote, as proof that Missourians oppose the federal health care law.

Nasheed said she expects that the Legislature will come around because of the impact on rural areas of the state, which are largely represented by Republicans.

Many of the outstate counties have higher percentages of people who would become eligible through expansion, even compared to the state’s urban cores.

“The people that they represent will be impacted far greater than the people in my district,” Nasheed said. “A lot of their people will be impacted by it.”

Aside from giving thousands of uninsured Missourians access to affordable health care, the expansion will lead to more jobs, say supporters, citing a study the University of Missouri released last fall.

A separate study released by the Rand Corporation, an independent global policy think tank, last week claims that states that do not expand Medicaid will face millions more in uncompensated care costs.

“Choosing to not expand Medicaid may turn out to be the more costly path for state and local governments,” said Carter Price, the study’s lead author and a mathematician at Rand, in a news release. “State policymakers should be aware that if they do not expand Medicaid, fewer people will have health insurance, and that will trigger higher state and local spending for uncompensated medical care.”

So far, 23 states, including Missouri, have decided to forgo expansion. Others, including Arkansas, have used the health care law as a chance to reform the program.

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