Rep. Ed Robb was surprised and angered by the one-vote rejection of a University of Missouri initiative to address the shortage of health care professionals, but he expressed optimism that a “model health care plan” will be approved in the House.

Robb declined to be talk with a television reporter waiting outside the Capitol hearing room after the vote earlier this month and hinted he was concerned he would be unable to avoid using strong language.

“I really don’t know what I would have said,” Robb recalled.

Gordon Lamb, MU’s former interim president, had developed and nurtured the proposal to expand the training of doctors, nurses and other health care professionals. It involved a broad spectrum of colleges and had statewide support from public higher education.

The Missouri Coordinating Board for Higher Education made the Preparing to Care plan its highest priority—except for an overall budget increase to cover inflationary costs—and the Columbia Chamber of Commerce did the same in its list of legislative priorities. But Gov. Matt Blunt scaled the original $39 million request down to $13.4 million, and House Budget Committee Chairman Allen Icet warned that Blunt’s spending proposals needed to be pared because of a possible downturn in the state economy.Robb, vice-chairman of the House BudgetCommittee, persuaded 13 of the 25 members todivert the $13.4 million from a new scholarshipprogram. The Missouri Department of HigherEducation had estimated that it could not spendthe funds.In the end, despite the independent funding,one of the committee members switched sides,leaving Robb and Rep. Steve Hobbs as the only Republicans backing the proposal.

Preparing to Care likely will get a second chance to rejoin the 2009 budget – either on the full House floor or in the Senate.But the vote could deepen the political troubles of Robb’s party in the legislature. Public opinion polls repeatedly have showed thatvoters disapprove of the Republicans’ 2005 vote to terminate the Medicaid eligibility of about 100,000 Missourians—often the sympathetic elderly, disabled and children—and scale back care for hundreds of thousands of others. Preparing to Care’s defeat, with the looming shortage of health care professionals, threatensto broaden the impact of those cuts.

Robb quickly defends the 2005 vote: “It was absolutely necessary to restore some fiscal integrity to the process,” he said. “We were going to run a deficit of $400 [million] to $600 million in a year the way we were going. The only other alternative was a fairly substantial tax increase” that ran counter to GOP philosophy.

But during the final two months of the session, Robb said, he believes the Republican-led legislature will back a plan to add health insurance for at least 200,000 of almost 800,000 uninsured Missourians—and possibly could leave as few as 50,000 in the ranks of those without health care coverage.

Robb’s optimism matches the relatively widespread hopeful note in the Capitol as lawmakers left for the annual spring break—a sharp contrast to the mood in late February. Then, after weeks of combative House hearings, Blunt had called off his plans to begin enrollment in his proposed Insure Missouri program in March. House members said the Blunt administration failed to get clear legal authority to launch the program that would have extended health coverage to about 190,000 working, low-income Missourians.

Last year’s Medicaid overhaul had merely authorized two pilot programs, urban and rural, but Blunt, social services officials and political advisers were relying on one-year appropriations language to launch the effort, despite legislative misgivings.

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Rep. Ed Robb

Rep. Rob Schaaf—a St. Joseph physician and head of the House Special Committee on Health Care Transformation—is now the central figure on health care issues.

He had been among the first lawmakers to challenge the governor’s legal standing, and he scheduled two dozen hearings that quickly spelled doom for Blunt’s plan over the rulemaking snafus.Schaaf and Rep. Doug Ervin, a fellow Republican and Clay County business owner, last week filed the bills (HBs 2398 and 2413) that likely will become the centerpiece of the session’s final two months. “It’ll be a beauty before it’s over,” predicted Robb about the likely debate.

As he warned in early January, Schaaf said he wants the legislature to write explicit grounds for the expanded health care program.

Schaaf readily acknowledged that the twin pieces of legislation are really nothing more than “placeholders” in the process, although the current language gives hints about where he and Ervin expect the program to evolve.

They propose opening the new health programs to Missourians whose income is 85 to 225 percent of the federal poverty level—roughly $17,000 to $47,000 for a family of four. Neither, however, proposes that the new Insure Missouri become an entitlement program, although they would tie into the Medicaid program and funding. The legislature’s appropriations each year largely would control how many Missourians are covered.

Persons over age 65 are not eligible, nor are persons who have had insurance within the last six months.

The program would offer services that appear to include all those under MO Healthnet, or the state’s new version of Medicaid.

Both build their plans on the requirement that program’s base would entail the use of “health savings accounts,” or tax-exempt funds that individuals would use to buy health services, but would have the normal insurance coverage of more expensive illnesses.

Both build their plans on the requirement that program’s base would entail the use of “health savings accounts,” or tax-exempt funds that individuals would use to buy health services, but would have the normal insurance coverage of more expensive illnesses.

Persons covered by the new version of Insure Missouri would contribute 1 to 5 percent of their income that they could use for discretionary health spending. The plans covered by Insure Missouri could have deductibles up to $2,500.

The state would provide most of the health savings accounts for the poorest residents.

“It’s an incentive not to use the [highly expensive] emergency room,” Schaaf said of the health savings accounts.

He expects program participants to shop around for the best deals.

The planners also would continue the Republican majority’s insistence on styling major health programs as “preventative” by making $500 in such services available at no charge but would require at least 85 percent of the program’s cost to cover direct health-care services.

He and Ervin also have filed legislation that would “increase transparency,” or make costs and benefits plainer for the average recipient. Question marks remaining for the program involve how it would affect businesses that employ large numbers of low-income wage-earners, particularly if they or their families have severe illnesses, such as diabetes.

Business groups in particular have been dissatisfied by state insurance laws that permit large premium hikes if one or two people covered in a small company’s group policy become seriously ill.

Schaaf said he envisions that the companies could simply shift the risk for such health costs to the state high-risk pool.

Ervin, who could not be reached for comment but opposed the Blunt plan, has proposed such language before. However, his bill provides for stop-loss insurance coverage for small companies in larger areas, which relieves the insurer of liability in limited pilot programs that would end in 2011.

Limiting the cost for such service-intensive individuals could dramatically lessen the cost of coverage for smaller companies and eliminate the risk of high premium increases upon renewal.

Sen. Tom Dempsey, a St. Charles Republican, has proposed instituting Insure Missouri under legislation he filed. But after two months of hearings, Schaaf’s committee likely would not likely begin the redrafting process on his bill. At this point, he would prefer to merge his legislation with Ervin’s as a mega-health measure.

Schaaf noted that the House and Senate likely will work simultaneously on the health insurance plans; whatever the House proposes, the Senate will need to cooperate in funding because the state budget will have passed the House by early April.

The House likely will complete its early action on the state budget next week and send it to the Senate.

The current document has no funding for Insure Missouri, which, under Schaaf’s and Ervin’s bills, would begin operating in January. If Schaaf’s timetable holds true, the House could not address funding until the Senate acts or a conference committee completes action.

Legislative Democrats generally have taken the policy position that the state must restore everyone cut in 2005 from the Medicaid rolls.

Rep. Sam Page, a St. Louis County doctor and Democratic candidate for lieutenant governor who sits on Schaaf’s committee, sees room for compromise in the coming weeks.

“The political reaction of voters in Missouri has been that they stated clearly these Medicaid cuts by the governor and the legislature were unfair. People in the Capitol are starting to get that. If you ask people on the street what is the most important issue, they say, ‘health care’. The people in the legislature are reading those polls. The Senate desperately wants to do something,” Page said.

Robb expects that in the end, the decision will come down to two factors: “size and cost,” including how best “to leverage” federal participation under Medicaid.

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