Another bought-and-paid-for legislative decision in Missouri can be traced to Sen. Kurt Schaefer

Missouri is about to kick off a process that will put private insurance companies fully in charge of the statewide Medicaid program. The move is on a par with Kansas’ controversial KanCare experiment, except that, for now, Missouri isn’t making the mistake of forcing its disabled and elderly populations into managed care — just low-income kids and very low-income parents in all of the state’s counties.

But unlike KanCare, which Gov. Sam Brownback’s administration rolled out with considerable fanfare in his first term, Missouri’s move to full-scale managed care has the feel of a covert operation.

“We had no hearings. None,” says Sen. Rob Schaaf, a Republican from St. Joseph. Schaaf, a physician, is one of the few lawmakers who balked at the change. “The people on Medicaid didn’t get a chance to weigh in.”

Neither did doctors, nurses, hospital administrators and others who will be affected. The Department of Social Services solicited their written opinions, but only after lawmakers had made the move a fait accompli.

This they did in a peculiar and unsound way. The Senate dictated the change late at night last year, while it was passing budget bills. The House went along with it.

Gov. Jay Nixon, a Democrat who generally takes a dim view of legislating through the budget process, signed the bill into law. Requests for proposals from insurance companies are scheduled to be issued this month.

Why the rush? Missouri already pays private insurers to administer the Medicaid program in half of its counties, those along the Interstate 70 corridor. No one has produced evidence that entrusting them with care of the 200,000 persons currently served by the traditional Medicaid fee-for-service program will save money or produce better health results.

The answer to that question, like the explanation for much of what goes on in Missouri government, has to do with campaign donations. The records of the Missouri Ethics Commission are loaded with chunks of cash from health insurers.

One of the biggest donors is Centene Corporation, with headquarters in the St. Louis area. It spent $170,400 on campaign contributions in 2015, doling out cash in varying amounts to dozens of lawmakers from both parties. The company spent $137,200 in 2014. From 2009 through 2013, Centene gave Nixon a total of $60,000.

Centene likely considers its political donations to be money well spent — and the same goes for its payments to seven lobbyists in Jefferson City. It is one of three insurers now holding contracts to manage the health care of almost 500,000 Missourians. (The other companies are Aetna and WellCare Health Plan.)

Missouri’s move to managed care can also be traced to Sen. Kurt Schaefer, the Republican from Columbia whose political ambitions (he’s running to be the state’s attorney general) and bullying tactics have driven attacks on Kansas City’s earnings tax, harassment of Planned Parenthood, and other poisonous developments in state government.

It was Schaefer, chairman of the Senate Appropriations Committee, who insisted on directing the move to managed care in the budget bill last year. He framed it as a way to get control of Medicaid costs, though there is no substantial reason to think that will happen.

Centene gave Schaefer $10,000 in donations after the 2015 session ended. Aetna chipped in with $1,000, and a WellCare subsidiary gave him $2,500. Rewards like that are business as usual in the ethical wasteland that is Missouri government. What really raised eyebrows in the Capitol was when a lobbyist named Yancy Williams recently showed up as a representative for the Missouri Association of Health Plans, a consortium of insurance companies. Williams was Schaefer’s chief of staff at the time the senator insisted on the managed-care expansion. He left Schaefer’s office in the fall of 2015 to become a lobbyist. So less than a year after helping private insurance companies gain about 200,000 new customers, Williams is on their payroll.

It’s your typical Missouri story. Not illegal, but hardly ethical.

If the General Assembly had bothered to hold legitimate hearings, lawmakers would have found many reasons not to expand managed care. The state Department of Social Services has reported that the portion of its Medicaid program under managed care saves an average of 1.7 percent annually, compared to the counties that use a fee-for-service arrangement for Medicaid patients. But the same study shows that medical providers receive 8 percent less under managed care. It also reports that, while differences were small, patients in the fee-for-service program fare better in 10 of 18 quality tests.

The Missouri Hospital Association questions whether managed care achieves any savings at all. It also has presented data suggesting that managed care doesn’t reduce unnecessary use of hospital emergency rooms, as would be expected. Health-care providers and advocates for the Medicaid population predict that full-scale managed care throughout Missouri will lead to lower pay for providers and less care for patients. The point of for-profit health care is to make money. There are only so many ways to make that happen.

Because the expansion targets mostly rural areas, advocates foresee transportation hassles, expenses and delayed care as patients in remote parts of the state are required to see in-network physicians.

“To us, it is an illegitimate decision,” says Jeanette Mott Oxford, a former state representative who is now director of Empower Missouri, which advocates on behalf of low-income citizens.

A lot of people agree with that, but prospects for stopping the managed-care expansion are slim.

A feeble hope lies with an entity called the MO Healthnet Oversight Committee, which was created by a 2007 statute and charged with providing “advice and approval” for major changes in the Medicaid program. The committee, which consists of lawmakers and professionals involved in health care, has twice voted to reject managed-care expansion. But legislative leaders seem inclined to ignore its existence. There is talk of a legal challenge, but that would be a Hail Mary.

When not counting campaign contributions, Republican lawmakers in Missouri like to rail against the concept of Medicaid and the option to expand it under the Affordable Care Act. Medicaid, they say, is a “failed experiment.” Yet legislators had no problem expanding the biggest portion of this so-called welfare bust. It won’t be good for patients and it won’t be good for Missouri.

But it’s good for the campaign cash.