Insure Missouri failure leaves reform in limbo

JEFFERSON CITY—The dust has begun to settle on the corpse of Insure Missouri, Gov. Matt Blunt’s rather sudden and unexpected conversion to using the state government’s power to expand access to basic 
health care.

But its failure has left health insurance reform on the state level in limbo, and one current effort, undertaken by the Missouri Foundation for Health, was quickly mired in a partisan skirmish.

Blunt on Tuesday accused the foundation of being controlled by Attorney General Jay Nixon, the presumptive Democratic nominee for governor. Blunt said the foundation has been unwilling to collaborate with the state to improve health care.

James Kimmey, the foundation CEO and president, told CBT that while Nixon appointed the original board, “no one is left from that original board and the members have all gone through an election process. The attorney general in my years of working here has never once asked us to fund any particular program and the governor is doing that now. It’s exactly what he accuses the attorney general of doing.”

Two years ago, Blunt led the Missouri legislature to eliminate coverage or reduce services to about 400,000 Missourians in the Medicaid program. But last September, Blunt announced a new program that would eventually add almost 200,000 to the rolls of government-funded health care.

For Missouri employers of low-wage workers, Insure Missouri promised a government-subsidized path to health insurance—an increasingly scarce commodity for that workforce, although its scope was unclear. Paradoxically, Insure Missouri excluded many of the poor and disabled who previously were cut and added able-bodied workers and parents who would cost less to insure.

Heading into 2008, before Blunt announced he wouldn’t seek re-election, the program lacked many firm details. By mid-January, early legislative hearings indicated that it lacked the most basic detail – the legal grounds for existing. The Blunt administration was relying on appropriations language, good for only one year, to launch the effort. Rules to launch the plan were stymied, Blunt shelved enrollment in the first phase and legislators began trying to write language to launch a whole new program for low-income workers.

By then, Blunt was a one-term governor, and his key staff was departing. The Senate revived Insure Missouri, but the House rejected it as the speaker and key committee chairmen became bogged down in a dispute over medical facility construction.

A joint conference committee removed Insure Missouri from the budget in May, sealing its fate.

Where does Missouri head now, as the number of uninsured has risen from 668,000 residents a year ago to 772,000, according to a U.S. Census Bureau estimate?

The mourners over Insure Missouri have no natural leader. Blunt is preparing to leave, and any bold policy initiatives are unlikely this year.
Nixon has adopted the standard party line about restoring the eligibility of those cut from Medicaid in 2005 – a line more useful to political rhetoric than policy formulation.

The Republicans vying for Blunt’s seat, U.S. Rep. Kenny Hulshof and State Treasurer Sarah Steelman, have hesitated to criticize the governor’s performance or propose alternatives for reducing the number of uninsured Missourians.

Business groups historically have avoided leadership roles on overarching health policy issues and showed little to no interest in Insure Missouri. Affiliated organizations are taking on segments of the overall issues such as transparency in cost and quality measures.

The public, however, shows an inclination to act.

Missouri voter interest was kindled after Blunt’s Medicaid cuts, and health care policy consistently ranks in the top three issues in national voter surveys. Small wonder: health insurance premiums for workers rose 87 percent from 2000 to 2006, compared to 16 percent for worker wages. In 2006, premiums actually slowed to a 7.7 percent rise – compared with a 3.8 increase in wages.

Taking the early lead in testing the waters here has been the Missouri Foundation for Health, which launched a campaign called Cover Missouri. The group is going to cities around the state and asking for ideas about how to increase health insurance access statewide, Thomas McAuliffe, a health policy analyst for the foundation, said. The foundation organized a forum in Columbia on Tuesday and plans to hold them soon in Poplar Bluff and Kirksville.

The state informational campaign coincides with a presidential campaign that observers expect to delve closely into the possible establishment of a national health care program, at least on the Democratic side.

The Republican nominee-apparent, Sen. John McCain, also has shown substantial interest in federal activity on health insurance. McCain has proposed relieving companies of the burden for providing the majority of financial support for employee coverage. He proposes ending the federal corporate tax deduction for such premiums and offering tax credits of $2,500 for individuals and $5,000 for families to buy coverage on the individual market.

Republican majorities in the Missouri legislature also have backed changes that would allow companies to leave the obtaining of health insurance to employees and their families – without getting the price breaks found in group purchases.

McCain also has supported broader use of health savings accounts, tax-exempt funds for out-of-pocket costs.

The problem: the tax credits are far smaller than the average cost of such policies, and most states do not require insurance companies to sell policies to families or individuals without regard to adverse health status. He has proposed that states set up pools – which Missouri has done to provide high-cost coverage to 3,000 persons – for persons generally regarded as uninsurable.

Sens. Barack Obama and Hillary Clinton have backed plans that generally provide universal coverage of all Americans, although Obama would not require them to obtain it. Businesses have been particularly sensitive to the fact that their health-insurance bills for employees have swollen as hospitals, doctors and other providers pass along the uncompensated care provided to the uninsured.

All three candidates leave room for states to design systems that differ, at least slightly, from the federal models.

The federal models – particularly those favored by Obama and Clinton – would overshadow any efforts Missouri could make to improve its market.
But among questions the Missouri Foundation for Health is likely to encounter as it explores health coverage in communities:

• Universality and community rating. Do Missourians firmly believe that they deserve care if they develop serious illnesses? Do they believe that all persons should pay comparable costs for coverage, depending on whether they have family or personal histories of disease?
• Individuals or families trying to obtain coverage in Missouri still face difficulties on those counts, often facing denial of coverage or far higher rates if they have a history of serious illness. For that reason, persons with illness histories often try to obtain group coverage and get better rates because their costs are averaged with healthier persons. Group coverage is not always the answer as many small businesses know. They often face substantially higher rates if one employee or dependent has a serious injury or illness.
• McAuliffe said some health-care leaders, even hospital administrators, favor “Medicare for all,” or extending the basics of America’s system of health care for the elderly and disabled to all. The system is widely accepted and has relatively low overhead costs compared with commercial insurers
• Standard benefits. While Missouri has adopted a fairly lengthy list of illnesses that health insurance policies must cover, it has never adopted standard benefit plans that allow individuals to shop easily for coverage. If businesses recede from their position as the principal buyer of health insurance in the state, individuals would have much more difficult decisions to make on coverage.

On Tuesday, shortly after the foundation’s presentation in Columbia, Blunt outlined what he called several opportunities for cooperation and suggested the foundation “make a 10 year commitment to several worthwhile projects.”

They included Mo HealthNet Outreach, several programs addressing children’s needs, including obesity prevention and treatment, and a tobacco cessation that uses vouchers for medicine.

Kimmey countered, “The impact of doing what the governor asked us to would be to take money away from non-profit agencies and give it to the state government and that doesn’t seem right to our foundation.”

Kimmey said its relationship with the state is to provide about $9 million in funding to community organizations and voluntary agencies for senior services and a variety of activities consistent with the foundation’s mission and goals.

“We actually put more money into many of the programs Governor Blunt mentioned, like the smoking cessation program, (which) the government hasn’t put any money towards,” he said. “ We feel we keep a pretty good balance.”