A major plank of Governor Matt Blunt’s 2007 legislative agenda – overhauling the state’s Medicaid program – remains unfinished as this year’s session enters its final weeks. In early April Senate sponsor and majority floor leader Charlie Shields (R-St. Joseph) brought SB 577 up for consideration. After several days of debate and the adoption of a variety of amendments the Missouri Senate approved the legislation and sent it on to the Missouri House of Representatives. The bill is now under scrutiny by a special House committee and has yet to reach the full chamber for debate.

Because the legislation is a priority of Governor Blunt’s, many expect its passage, but its fate remains uncertain. SB 577 has ballooned into an ambitious 75 page bill that currently renames the Medicaid program MO HealthNet, moves the elderly and disabled into managed care plans typically used to address the health care needs of more healthy populations of children and young adults, declares a goal of finding a “health care home” for each recipient and a “health care advocate” that will coach people on how to adopt healthier lifestyles.

The overall focus is on prevention and steering people to primary care physicians instead of last resort emergency room care. The goals of the legislation are commendable but the legislation is too vague in many details. What constitutes a person’s “health care home” is never defined. Presumably it could be the primary care physician, a hospital or clinic or even a managed care company. The health care advocate supposedly is charged with representing the patient, but could be an employee of a managed care company more concerned with reducing costs for the company.

During debate on SB 577, the Senate defeated several amendments to restore Medicaid health coverage to some of the over 100,000 Missourians who lost health coverage due to the legislature’s 2005 funding cuts. An amendment proposed by Senator Victor Callahan (D-Independence) would have restored health coverage to an estimated 37,000 working parents. The Callahan amendment, drafted and championed by the Missouri Catholic Conference (MCC), proposed that some of the earned income of working parents be disregarded when determining Medicaid eligibility.

Senator Callahan argued the amendment would help those who wait on tables, clean the state Capitol at night and struggle every day to put food on the table. In its letter to state senators, the MCC said the proposal would be a way “the state of Missouri can demonstrate its respect for the dignity of work and workers.” Due to the 2005 funding cuts a mother with two children can now make no more than $3,504 annually (only 20.4% of the federal poverty level) to remain eligible for Medicaid.

Senators opposing the Callahan amendment argued the state could not afford the $58 million price tag. The MCC has sought to convince lawmakers that if full restoration of the Medicaid cuts is not possible, then some partial restorations should be adopted. Restorations under consideration include restoring health coverage to several thousand disabled workers and reinstating Medicaid services relating to hospice care and the provision of durable medical equipment.

Most of this year’s Medicaid debate, however, has focused not on restoring Medicaid services but on restructuring the program in order to save taxpayer money, root out fraud, promote quality care by Medicaid providers and encourage Medicaid recipients to adopt healthy lifestyles like quitting smoking. SB 577 requires Medicaid recipients to sign “health improvement participation agreements” in which they work with their health care advocate on a plan of action to improve their health. The MCC has expressed support for this goal but cautioned senators that denying medically necessary services to patients because they failed to live up to their agreement raised troubling ethical questions. In response, the Senate amended the bill to clarify that failure to comply with the health improvement agreements would not result in the denial of such services.

One of the more complicated sections of SB 577 seeks to move more of the elderly and disabled into managed care plans in order to reduce Medicaid expenditures. In its letter to senators, the MCC noted that cost savings for this population would be difficult to achieve and observed that a managed care program for the elderly and those with disabilities would require an extensive array of specialists providing care for a variety of medical conditions. As approved by the Senate, the bill includes a provision allowing the elderly and disabled to “opt out” of managed care plans they are assigned to. But concerns remain that many elderly and disabled will be confused if they are automatically assigned to managed care plans without proper consumer education that they have other options.

Even if SB 577 is finally approved by the legislature it is becoming clear that more work will remain, especially in addressing the needs of the over 660,000 Missourians without health insurance. The legislation proposes establishing a program that would help employers and employees pay for their private health insurance. This “premium offset” program may have merit for some modest income families above the federal poverty level, but the MCC is pointing out to lawmakers that the very poor have to use their income to feed their families and keep the family car running. There is simply no money left to pay a monthly health care premium.

Underlying all of the debate regarding Medicaid reform lies a philosophical divide between those who see Medicaid as a pernicious form of welfare that gobbles up precious state resources while undermining self-reliance and personal responsibility and those who view publicly funded health insurance as vital for lower income workers who either cannot afford the health insurance offered by their employer or work for an employer that does not offer health benefits. According to the Kaiser Family Foundation, in 2005 15% of employees worked for employers that did not offer health insurance.

It should not matter if a worker is a cook, a farmer, a mechanic or a brain surgeon as to whether health benefits are provided. All work has dignity and our state should honor work by enacting policies that promote just wages and adequate job benefits, especially health coverage. But if work on SB 577 is any indication, the legislature has a long way to go before social justice of this kind is seriously considered.