Missouri Republicans may need to shift Medicaid strategy after Pennsylvania decision

Sept. 04--Some Missouri Republicans say they're willing to expand Medicaid -- provided that new recipients look for jobs as a condition of eligibility. But a new agreement between the federal government and Pennsylvania suggests that strategy probably won't work.

Pennsylvania's plan to provide coverage to as many as 600,000 low-income residents was approved last week, but only after its work-search requirement was dropped after stiff resistance from the federal government.

Many of the states, including Missouri, that didn't expand Medicaid because of opposition to the Affordable Care Act have been looking for ways to tailor their programs to overcome political objections. Pennsylvania was among six states that sought waivers from the Centers for Medicare and Medicaid Services, or CMS, to make changes to their public insurance plans.

"CMS appears to be willing to kind of work with states and give them flexibility to come up with programs that fit specific state needs," said Cora Walker, a professor at St. Louis University's School of Law.

Missouri's Republican-led Legislature has taken a similar approach in debating whether to expand Medicaid, arguing the current program needs significant changes before more people are added.

But Pennsylvania's negotiations with the federal government could dampen Missouri's efforts as it relates to requiring new Medicaid recipients to actively seek work or enroll in a job-training program.

Pennsylvania, 26 other states and the District of Columbia have agreed to provide federally funded insurance coverage to adults with incomes up to 133 percent of the federal poverty line -- about $15,500 for an individual -- under the provisions of the health care overhaul.

Although the Missouri Legislature has repeatedly refused to join the ranks of states expanding coverage, citing concerns about the costs to the state and federal government, some Republicans have put forward plans that would lift the program's eligibility level only if Missouri is successful in obtaining waivers from the administration of President Barack Obama.

One of those ideas proposed during this year's legislative session was a work-search requirement.

Tom Corbett, the Republican governor of Pennsylvania, had initially proposed such a requirement, but the state agreed to drop that demand in favor of a voluntary pilot program after opposition from the Obama administration. No state has a work requirement for its Medicaid program.

Legal experts said that while the federal government is willing to negotiate aspects of the Medicaid program to get states to boost eligibility, a work-search requirement isn't one of them.

"The federal government is very eager to encourage as many states to expand Medicaid as possible," said Joan Alker, executive director at the Center for Children and Families at Georgetown University. "They have also made clear there are some lines they won't cross."

Walker, the SLU professor, said a work-search requirement could be duplicative because many Missourians that would be eligible for Medicaid expansion already have jobs and that it could be an administrative burden on state agencies.

"Having a work requirement component doesn't really do anything to advance the overall goal of Medicaid, which is getting people to have access to health coverage," she said.

The Missouri proposal that included the work-search requirement would have expanded Medicaid eligibility to about 300,000 low-income residents. The sponsor of that measure said he hasn't closely reviewed Pennsylvania's agreement but said he plans to press on with his plan, including the work-search proposal.

"Nothing has changed for me and I am going to move forward with the legislation I proposed last year," said Rep. Noel Torpey, R-Independence.

Under Torpey's proposal, the work-search requirement would not have applied to new recipients that were deemed "medically frail," including those with developmental or mental disabilities.

Alker said states cannot require recipients to search for work as a condition of Medicaid eligibility, but said they could find other ways -- at their own expense -- to promote behaviors they think are important for Medicaid recipients.

She suggested that states, like Pennsylvania, looking to charge premiums to recipients with incomes higher than the federal poverty line could agree to reduce those costs for those enrolled in a job-training program. (Alker said the federal government has also shot down letting states charge premiums to recipients with incomes below the poverty threshold.)

Torpey's proposal would also have sought to provide incentives for healthy lifestyles and would have charged recipients who abused the emergency room or failed to use preventive services.

Torpey said he plans to talk with Pennsylvania lawmakers about their Medicaid agreement and could modify his plan based on their experiences. But he reiterated that expanding Medicaid eligibility in Missouri would depend on changes to the program that likely will require federal waivers.

Although Pennsylvania's agreement pours cold water on implementing a work-search requirement in Missouri, it still could provide a political path forward for Republican opponents.

"When you have Republican governors pushing the envelope it certainly helps things in Missouri," Torpey said.

This report was prepared in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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