Big Medicaid expansion vote looms in Mich. Senate

Two months after putting off a decision on whether to expand Medicaid to more low-income adults, leaders of the Michigan Senate are looking to hold their much-anticipated vote.

The showdown in the Republican-dominated chamber on Tuesday or Wednesday could determine whether hundreds of thousands of state residents will qualify for government-provided health care starting in January.

Here's a look at the issue and dynamics at play:

The 2010 federal healthcare law has a two-part strategy to ensure nearly all Americans have health insurance. One is Medicaid expansion, which was designed to cover the neediest uninsured people but became optional for states because of a Supreme Court decision last year.

Medicaid already covers 1.9 million, or one in five, Michigan residents — mainly low-income children, pregnant women, the disabled and some poorer working adults. The debate is whether to cover nearly a half-million more adults making up to 133 percent of the poverty level, or $15,500 for an individual and $26,500 for a family of three.

Republican Gov. Rick Snyder is lobbying for the expansion along with the medical and insurance industries, Democrats, some GOP lawmakers and advocates for the poor. Snyder says those who would be covered now use the emergency room for medical care — which he says is unacceptable, expensive and leads to higher premiums for businesses and individuals with private insurance. Reducing those ER visits by giving people an insurance card to go to the doctor will save money, according to proponents.

The expansion is fully financed by the federal government for the first three years and phases down gradually to a 90 percent federal share. The state would save money initially but owe later on. Cumulative costs would exceed savings in 15 years, according to the nonpartisan Senate Fiscal Agency. Snyder also says the Affordable Care Act is here to say, so Michigan might as well get something in return for the new taxes coming under the law.

Nearly half of the Republicans in the GOP-led House voted to expand Medicaid in June once provisions were added to make recipients pay some of their medical expenses, incentivize them to be healthier and give Michigan escape hatches if Washington changes terms of the expansion. But many Senate Republicans oppose it. They have a philosophical problem with expanding government. Conservative groups and grassroots activists are suspicious of contentions that Medicaid expansion will save money and say the program is broken. Blocking the expansion also is a way to thwart "Obamacare" nationally.

Twenty-three states, including six led by GOP governors, and the District of Columbia have decided to accept the expansion. But nearly two-thirds of low-income Americans newly eligible for Medicaid live in states that are refusing the expansion or are still undecided. Snyder, like Republican Gov. John Kasich in Ohio, is trying to persuade a GOP-controlled Legislature to go along.

There's no deadline for states to decide. But if a state is going to accept the expansion, it makes sense to do it now because it's paid for entirely by the U.S. government in 2014, 2015 and 2016. States can drop out later if they want.

It may already be too late for Michigan to start covering more enrollees on Jan. 1. The legislation pending in the Senate would need approval from the Obama administration, which could take months.

Snyder spent the summer traveling to GOP senators' districts to push publicly for Medicaid expansion, and pro-expansion allies paid for billboards calling on Republican senators by name to support the expansion. But in the end, a lot depends on one senator: Majority Leader Randy Richardville.

The Monroe Republican supports the expansion but decided against calling a vote in June despite a request from Snyder. The governor said enough Republicans would have joined 12 Democrats to pass the bill. Richardville said he wanted at least half the 26-member Republican caucus to support the bill or at least be OK proceeding to a vote and later said he saved the legislation from going down in defeat.

As promised, Richardville took time to name a workgroup and hold hearings on the House-passed legislation that resulted in changes to the bill.

Though it doesn't appear that Snyder has picked up more support — some Republicans thought to be on the fence now seem firmly opposed — his aides remain confident they have eight Republicans votes to get the 20 needed. If only seven Republicans support the bill, then Lt. Gov. Brian Calley could break the 19-19 tie.

Asked recently if he will drop his preference that more Republicans be receptive to having an up-or-down vote, Richardville said: "If I believe it's the right thing to do, I'll do that."

One factor causing unease among proponents of the expansion: Richardville's committee also sent to the floor two conservative alternatives designed to cover the uninsured without expanding Medicaid. The Snyder administration questions the cost of the proposals and has concerns with the quality of health benefits that would be offered.