Scenes from the health-care struggle in Jefferson City
The walls of the Capitol in Jefferson City are etched with lofty phrases about liberty and justice. But the quotes from long-buried visionaries aren’t what make Adrain Graham think about Independence Day. Her reason for confronting Missouri’s House of Representatives is etched in the scars trailing down the left side of her body.
Last year, Graham was celebrating the Fourth of July outside her tidy home on Kansas City’s East Side. She lit a firecracker and placed it in a metal tube that was meant to fire it safely away, like a canon. She waited but heard no sound, no fizzle as the fuse burned down. She leaned forward to check.
At that moment, the firework exploded.
She emerged from a coma five days later at the University of Kansas Medical Center, third-degree burns slicking her left arm, one shoulder and half her chest. She had to wear “a Darth Vader suit,” she says, so the skin on her arm wouldn’t adhere to her torso. Doctors skimmed flesh from her left leg and grafted it to her shoulder.
After a month in the hospital, her bill totaled more than $30,000.
Graham works full time at Care Staff, a local nursing agency. She earns about $1,000 a month, barely enough to cover living expenses and the needs of two teenage kids. It’s not enough to pay for health insurance.
She used to be covered through the state’s Medicaid system. But that changed in 2005, when then-Gov. Matt Blunt and the Missouri Legislature tightened eligibility requirements. Instead of allowing a family of three living on nearly $12,000 a year into the system, the state cut eligibility to the minimum required by federal law. Now, a single parent with two kids can earn no more than $3,500 a year to get Medicaid coverage.
Graham was one of thousands kicked off the rolls. Faced with a five-figure bill she couldn’t pay after the accident, she applied for emergency Medicaid coverage. She was denied. “They said I made too much money,” she says with a still-disbelieving smile.
Like a car-crash victim or a lifelong smoker diagnosed with cancer, Graham has found herself propelled into a costly health-care system she now can’t escape. She still regrets that fleeting moment of thoughtlessness. She thinks about it every time she hears a loud bang in her neighborhood.
On a mid-April morning nine months later, she’s among a small army of Kansas City residents in Jefferson City urging legislators to expand health-care coverage. Missouri now ranks in the nation’s bottom five states when it comes to parent eligibility for Medicaid, and lawmakers, they argue, should do more to help the state’s most vulnerable citizens, especially during a period of high unemployment. Shifting uninsured residents to programs such as Medicaid
makes sense, they say, because otherwise those citizens wait until a crisis forces them to seek medical attention — often leaving hospitals and taxpayers stuck with the costs.
They scatter in groups of three and four, crowding the hallways outside the House chamber as they share their stories with policymakers. It’s easy to sort the Democrats from the Republicans. Democrats tell the visitors that they’re still fighting to expand health-care eligibility. Republicans give stiff apologies, saying the state can’t afford to add even one more person to state-subsidized health care.
After a midday rally in the rotunda, the group parades through the hallways to the office of Gov. Jay Nixon. As they walk, they so forcefully bellow the gospel song “This Little Light of Mine” that perplexed workers peer out of their offices to witness the commotion. By the time they reach Nixon’s office, building security is there to warn against their noisy conduct.
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That impromptu raising of voices isn’t nearly as loud, though, as the bitter fight on the floor of the Missouri House of Representatives.
There is a triangle of power in Jefferson City that decides who gets a slice of the state’s $23 billion budget. At one of those points sits Allen Icet.
A Republican from Wildwood, the dark-haired engineer behaves with Victorian decorum. His back seems always straight. His elocution is precise. He takes a dim view of handouts.
Icet is the House Budget Committee chairman, giving him a grasp of the state’s purse strings rivaled only by Nixon and Senate Appropriations Chairman Gary Nodler. Icet constantly raises the specters of New York and California — states, he warns, that have spent themselves into oblivion. Missouri’s financial situation is far less dire. Still, when the governor releases his proposed budget on January 27, 2009, Icet is poised to challenge any spending increases.
Two of Nixon’s health initiatives stick in Icet’s throat. The governor wants to tweak the State Children’s Health Insurance Program
(SCHIP). In 2005, Blunt increased the number of families that have to pay a monthly premium to get coverage and he also upped that premium for others. Thousands of kids fell out of the program. Nixon wants to get 27,000 of those children back by eliminating or lowering fees. To do that, he adds an extra $13 million to the program — an offering that will bring a $42 million federal influx.
Icet thinks those parents should be responsible for their own children. His revision: zero additional assistance for SCHIP.
Nixon also wants to restore Medicaid access for some of the 90,000 parents who have been bounced from its rolls since 2005. To do it, the Missouri Hospital Association
has agreed to a slight, voluntary adjustment to the state’s hospital tax that would put an additional $52 million in the bank and draw down an extra $93 million from the feds. It wouldn’t cost taxpayers a dime.
Icet suspects that many of the parents wanting Medicaid aren’t working a full-time, minimum-wage job. His budget revision: no Medicaid expansion.
The Republican uses his point in the triangle to hack off the governor’s health-care initiatives.
Jason Kander, a state representative from Kansas City who looks like a high-school student but speaks with the quiet resolve of a college professor, is one of 13 Democrats who is spending his late-winter days wading through a 3-inch-thick stack of budget documents. The 28-year-old freshman is irked by a system that seems rigged in the Republicans’ favor. The governor’s budget is gone. The only version that Kander and his colleagues have to work with is Icet’s.
The Democrats are handcuffed by House rules, too. They can add funds to a budget line only if they subtract the same amount from somewhere else in the budget. To revive the governor’s health-care initiatives and add funding to SCHIP, the Democrats try to chip away at other programs and suspend the “balancing rule” altogether so they can discuss the Medicaid idea. The Republicans use their three-vote edge to shut them down.
It’s just a taste of what is to come.
In the Missouri House, the narrow strip of carpet dividing the dark wooden desks of the 89 Republicans and 74 Democrats might as well be a high brick wall.
On the Democrats’ side, it’s the job of House minority leader Paul LeVota, a Democrat from Independence, to find cracks in that wall, to heave over facts and line up allies who will bring down the Republicans’ partisan defenses.
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On health care, LeVota thinks his side has foolproof ammunition. Nobody wins when low-income families can’t afford basic preventative care and seek medical attention only when a crisis pushes them to the emergency room. That equation burdens hospitals with unpaid bills that, one way or another, people with private insurance pick up. The economic argument hasn’t just won over the hospital association but also has garnered the support of the business lobby: the Associated Industries of Missouri.
“What I’m trying to do is deal with the situation we have in the state: that is, the highest unemployment rate in years, people without health care for years,” LeVota says. “I want to create a better economy in this state. I want to invest in health care for kids and health care for the working poor that will not cost one dollar of general revenue.”
Unlike Icet, LeVota plays along with the House’s unofficial “Bowtie Wednesdays,” wearing a colorful cravat that looks strangely tiny pinned on his stocky frame. Despite his amiable air, though, LeVota is fiercely partisan.
On this particular day, March 25, the House is debating the budget bill, and emotions are running high. LeVota and the Democrats want to do what Kander and the Budget Committee couldn’t — replace the health-care expansion. But the Republicans are adding bricks to their wall.
First comes Rep. Tim Flook, a Republican from Liberty in door-to-door salesman’s clothing. His voice edges up to a shrill shout as he insists that Missouri not depend on the federal government to provide more services.
“When we bite off on that bait and say, ‘Take those federal dollars! Soak ’em up! Spend ’em!’ … all we’ve done is played that game of who pays. And when government pays, we all lose. If we want to be strong, we’ll tell Congress we’re not going to take that money and do dumb things with it.”
The Liberty Republican continues for several minutes.
“In a year when we’re all hung over from our drunken spending spree and the headache has come in ….”
Crack!
“Gentleman, your time has expired,” Speaker Ron Richard
says, banging the gavel from the front of the chamber.
“Give him more!” a Republican member shouts.
“Flook, Flook, Flook,” the conservative side of the aisle chants.
But Flook isn’t the highlight of this show.
Later, Rep. Rob Schaaf, a Republican from St. Joseph, leverages an explosive argument. The slight physician stands at the microphone, a portrait of Abraham Lincoln over his right shoulder, and launches into a plaintive speech about the role of legislators. When the government picks up the tab for parents or children in poverty, he says, drawing out each word for dramatic emphasis, the result is worse than welfare.
“That, Mr. Speaker, is slavery,” Schaaf says. “And that man on the wall tried to end it in our country, and they want to bring it back! That is the difference between the two parties. We need President Lincoln to come back and lead us.”
Across the aisle, Rep. Shalonn “KiKi” Curls, a Democrat from Kansas City, is astonished. As she moves, still in disbelief, to her microphone, the Republicans cheer on the confrontation.
“Uh oh!” they jeer.
“Let’s keep the conversation clean, gentlemen,” Richard warns.
“Gentleman, am I right that you have likened providing health care to those who are less fortunate to slavery in the United States?” Curls asks Schaaf in a measured tone that barely conceals her anger.
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The Republicans burst into laughter.
“Oh, no,” Schaaf says. “I said when the government forces a person to work and pay the fruit of their hard-earned labor and gives it to benefit someone else who could work — that is slavery.”
“It’s difficult to stand here and listen to this,” Curls continues. “I am personally offended, absolutely I am …. We are spending money in other areas, and some of that is OK. But, please, do not criticize trying to do more for the people who need us the most.”
The debate runs into the night. “Today we engaged in an orgy of partisan rancor,” Democratic Rep. Chris Kelly
says angrily as the tense exchange sputters to a close, “and none of us is without stain.”
The House Republicans have another assault to contend with, though: their own conservative colleagues in the state Senate.
A month later, on the last day of April, spectators wedge shoulder to shoulder along a beige velvet rope in the House Legislative Library, jockeying to hear the run-up to a showdown. Lobbyists and state officials stand like bookies before a horse race, jotting down notes.
Beyond that velvet rope, 10 members from the Senate and the House — two Democrats and two Republicans from each chamber, plus the Republican budget chairmen from each — sit around a large wooden table. There’s Icet, rigidly upright, barely bending his neck to peer down at his budget packet. Next to Icet, co-chair Nodler looks pale and pasty as he slumps on his elbows. His face seems frozen in a slightly patronizing smile.
These lawmakers have 13 bills in front of them that make up the budget. They will go line by line, deciding which chamber will get its way on each item. Because one side of the room opens into the noisy rotunda, the library is an echo chamber that rings with the squawks of touring schoolchildren. On this particular day, a victims’ rights group has gathered for a rally, complete with a church chorus. Though the legislators have to cup their ears to hear one another, they move quickly through each stapled section.
“Maybe the choir of angels works,” Nodler says as the singing filters in.
“Keep ’em singing,” Icet replies dryly.
The reason for the spectators is in House Bill 11. That’s where the Medicaid funding goes. While Icet has held the line against expansion in the House, the Senate Republicans want to cover more impoverished residents. Sen. Tom Dempsey, a Republican from St. Louis, has proposed a bill that would raise Medicaid eligibility to 50 percent of the poverty level but provide coverage through a private insurance system that uses health savings accounts. Where Icet has marked a zero for Section 11.517 of the House budget, the Senate has penciled in the $52 million that Nixon had coaxed from the hospitals.
When the legislators finally flip to Section 11.517, Icet and Nodler skip it.
“Why did they do that?” a short man in a tan suit asks a lobbyist near the door.
“Because they don’t want to get mad at each other and storm out,” the lobbyist says with a smirk.
By the time the legislators square away all the other aspects of the budget, it’s 4:30 p.m.
“Now we’ve come to the elephant in the room,” Nodler says.
The spectators, buried behind their tiny BlackBerrys for hours, snap to attention.
“Everybody has discussed the issue, thought about the issue, prayed about the issue,” Nodler says. “Now it’s time to decide the issue.”
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“I won’t belabor the point,” Icet says, “but there are a significant number of members of the House who have significant heartburn on this.”
As the two leaders confer quietly, Icet holds a copy of the budget in front of him, and Nodler tucks his face behind it. Now the room is quiet. A peanut M&M clinks on the glass tabletop like a marble on sheet metal. Finally, after several minutes, Icet and Nodler re-emerge.
No agreement.
By the time they return on Monday, May 4, the leaders have struck a backroom deal.
Yes, the Medicaid money will stay in the budget. If the Senate’s private insurance plan passes, that’s how the money will be used. If not, those millions will go to a Medicaid expansion.
Icet doesn’t like it and doesn’t sign the bill — a very unusual move for a budget chairman. He doesn’t file HB 11, either. By noon on Tuesday — with just three days left to pass the budget — he buzzes past his secretary and sets a budget file on her desk with a half-joking command: “Guard this with my life.”
Sitting in his bright office, he doesn’t seem frazzled. He thinks that Blunt’s Medicaid cuts have made the system more efficient. Making health care free, he reasons, leads to overconsumption. “I believe the majority have philosophical concerns that, if we continue, the end result is socialized health care,” he says.
After lunch, Icet is still sitting on the bill. Democrats and lobbyists start to wonder if he’ll refuse to file it. The Senate sends envoys across the rotunda, urging Icet to stop dragging his feet. Finally, late in the day, Icet changes his mind. He wants to give his colleagues a chance to debate the bill.
Instead, he gets a show.
The next day, the hallway outside the House chamber is clogged with men in suits. Lobbyists lean in close to confer with legislators, trying to make inroads in the final minutes. Because enough members are on the fence about the HB 11, nobody knows what’s going to happen.
One lawmaker in the cross hairs of indecision is Rep. Chris Molendorp, a Republican from Raymore. An earnest man with a self-effacing sense of humor, Molendorp has served on his local hospital board and sells insurance for a living. He knows the predicament that hospitals are in and the struggle that low-income folks face trying to afford health care.
The 39-year-old family man considers himself a citizen legislator. He says he has no interest in climbing the political ranks. In the few months since he arrived at the Capitol, he has broken with the majority party several times. It’s no secret that he could vote with the Democrats on HB 11.
A little before 4 p.m. the doorman brings Molendorp a card from Dustin Allison, deputy chief of staff for Nixon. Surprised, Molendorp puts it in his breast pocket and steps into the crowded hallway. According to Molendorp, Allison meets him outside the chamber and asks if he “shares the governor’s vision” on health care, then tells him that if he were ever “interested in a future career change,” the governor would look favorably on a yes vote today.
Molendorp is uncomfortable. The entreaties from Allison are ill-timed. Over the past couple of months, the Capitol has buzzed with reports that the FBI is investigating a “pay to play” culture in Jefferson City. Rumors have swirled that campaign contributions have bought prime committee appointments.
Molendrop excuses himself and slips back into the chamber. He surveys the other desks on the Republican side. At least two other possible swing votes are missing — Anne Zerr is gone, and so is Scott Largent. Sweating the ethics, Molendorp sets off a chain reaction.
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He tells Richard about his conversation with Allison. Richard tells Rep. Bryan Pratt, a boyish-looking Republican from Blue Springs given to gripping colleagues on the shoulder as he saunters the halls and aisles. But Pratt’s breezy demeanor turns stoic on health care.
Pratt voted for the Blunt Medicaid cuts in 2005; this session, he has derided Democrats for trying to max out the state’s credit card by “expanding welfare.” What Richard tells Pratt turns the glad-handing class president into the schoolyard bully.
Allison’s alleged promises are about to derail the budget debate.
Furious, Pratt charges into the hallway looking for the governor’s aide. The two square off in the back gallery. Molendorp is getting a drink in the back gallery when he hears Pratt shout, “Oh, how I wish the FBI was wandering the halls today!”
As Pratt continues his outburst, the Democratic side of the floor erupts in a sea of raised fists clutching white papers, frantically trying to get the speaker’s attention. LeVota barrels down the center aisle toward Richard.
Crack!
Richard bangs the gavel. “I figured this was going to get a little bit testy,” he says with an almost patronizing tone. “Keep it clean, or I’ll clear the building and we’ll vote on this thing tomorrow.”
“Is he going to apologize to our governor?” LeVota yells, midway up the aisle.
Richard doesn’t call for an apology, but he does ask Pratt to stick to the bill.
“OK, let’s talk about this bill,” Pratt says. “Is today the right time or wrong time to expand welfare in the state of Missouri? Our world is in the middle of a worldwide recession. Our country is in the middle of a recession. And in Missouri, we’re facing a recession …”
“Thank George Bush!” a Democrat yells.
“That’s the question we’re faced with right now,” Pratt continues. “And I can hear the howls from the other side of the chamber.”
A chorus of Democrats loudly draws out a unison response: “Hooowwwllll!”
The debate continues for the better part of an hour. Meanwhile, the governor’s office works up a press release responding to Pratt’s finger-pointing. “This baseless accusation is a weak attempt to distract from the issue of providing health care to 35,000 Missourians at no extra cost to taxpayers,” the statement reads.
Just before 5 p.m., the floor leader calls for a vote. Four Republicans side with the Democrats, but it isn’t enough. The bill is defeated, less than 48 hours before the budget deadline.
As the sun inches toward dusk, 72 Democrats gather outside on the Capitol steps. LeVota, with an army of grim-faced colleagues towering behind him, excoriates the Republicans for voting down free health care in favor of ideological pride.
Two members of LeVota’s caucus are missing. Kelly and Curls are already back at the bargaining table for a late-night session to save the budget.
At 8 p.m., the 10 members are again seated around the table in the Legislative Library. Lobbyists and other legislators hover over them in a tight circle, further eclipsing the room’s already dim light. If this group can’t come up with a way to get the Republicans to swallow HB 11, the General Assembly may be forced into an expensive extra session.
Kelly stabs at the remnants of beef and broccoli on a Styrofoam plate. They’ve already been at it for more than an hour.
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“So we have a compromise on the table,” Nodler says.
The Democrats are leery. The compromise says the Medicaid funding has to be part of the Senate bill, the private insurance proposal. If the two chambers can’t agree on some version of the Senate’s plan, not one extra person will be added to the insurance rolls. A simple Medicaid expansion is no longer on the table.
“Would I be impolite if I were to describe this as a pig in a poke?” Kelly asks. “Or would I be impolite and accurate?”
“I feel very uneasy signing a report on a bill we haven’t even made a decision on,” Curls adds.
After the two sides sequester themselves down opposite, abandoned hallways for discussion, the Democrats come back still unconvinced.
“Some people are concerned that it might wander down a dark alley and never be seen again,” Kelly says of the compromise bill. “Can you give me any assurance on its continuing progress?”
Icet deflects responsibility, saying it would fall to the House majority floor leader.
“Do you foresee the funds providing some coverage up to 50 percent?” Curls asks of raising the income cutoff for Medicaid. “That allows me to know if we’re proceeding in good faith or if we’re wasting our time here.”
Icet says he’d be “reluctant to commit” to that.
The Democrats are virtually powerless. With only four of the 10 members, they don’t have the numbers to swing a vote in their favor. All they can do is agree to the compromise and hope that the Republicans will play fair.
They concede.
Nodler passes a yellow folder counterclockwise around the table. Each member scrawls a signature across the bottom of the page. Curls spins her red BlackBerry anxiously on the table. When the folder gets to her, she passes it on.
“I’ll sign last,” she says.
On the morning of Thursday, May 7, with a week left in the session, LeVota is ready to admit defeat. Slugging his first Diet Coke of the day, the minority leader sits at his desk, under a poster of Abraham Lincoln with the word “Perseverance” written in cursive under the president’s face.
But LeVota has given up.
“The most frustrating thing is, these House Republicans are the most right-wing of the Republican party,” he says. “I mean, it’s like they have no realization that the people of Missouri want this and sent a message in the last election. Instead they’re even further to the radical side of this.”
An hour later, LeVota takes aim at Republicans on the House floor. Across the aisle, the carpeted gap now an ideological canyon, LeVota calls out Icet.
“I take great issue with your terminology of this being a compromise,” LeVota says to Icet. “You got your way. The gentleman from Jackson County [Pratt] got his way. You rolled the Senate. Thirty-five thousand people are not going to get health insurance. Congratulations.”
“Well, my way was nothing,” Icet retorts. “So I think I compromised in good faith.”
Finally, the budget passes. But the compromise gets twisted.
A Republican-led committee works through the weekend, churning out its own version of the Senate’s health-care expansion.
The document that emerges doesn’t cover working parents, as the Senate plan did. It doesn’t loosen eligibility restrictions. It deals with people who make far more money but have health conditions that disqualify them from normal insurance. During debate, a Republican member attaches an amendment requiring anyone who applies for public assistance to be subject to a drug test.
Some Democrats, including Kander, continue to hope that some sliver of reform will be worked out between the two chambers. But his optimism is tempered; Kander says he has already learned about House Republicans. “They completely lack seriousness,” he says. “They care about stuff that sounds good politically. They don’t care about governing the state.”
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Indeed, the Republicans allow any health-care compromise to slip through their fingers.
Senate leaders scramble to appoint their members for compromise discussions on Wednesday afternoon. By noon on Thursday, Republican House leaders haven’t bothered. They don’t even keep the lights on until the end of the business day; they adjourn the House at 4 p.m. On the other side of the building, the Senate continues discussions until 3 a.m. and attaches health-care provisions to another bill.
On Friday, the last day of the session, House Republicans sit on the Senate’s bill. No debate. No vote.
Game over.
On a late spring afternoon, Adrain Graham sits at her family’s dining table, still wearing the pink scrubs she wore to work that day. Along the wall, fish dart around a large tank that her fiancé bought to relax her when she was stuck in the house for months after surgery, unable to work, unable to expose her skin to the sun.
She has photos of her burned flesh, scorched and weeping like candle wax. She has a $30,000 hospital bill on a table in the family room, too.
After she was out of work for months, she explains, her income dropped enough that she qualified for emergency Medicaid coverage. But that will expire this month. When she says she’s disappointed that legislators failed to expand health coverage, there’s confusion in her voice. Even her meager salary would likely have made her ineligible for an expansion that the Republicans fought as too generous. She just doesn’t understand how elected leaders could have passed up a deal that would have helped so many people — people who are in even tighter circumstances than herself.
Graham needs another skin graft on her shoulder, but she can’t afford it without insurance. She can’t afford the medication that mutes the pain from the nerve damage on her left side, either. If her symptoms go untreated, she may not be able to work.
“The pain I’m in, what am I going to do?” she wonders.
Icet doesn’t have any advice for adults like Graham.
“That a good question,” he says in his office after hearing about her predicament.
Thinking it over, the always upright Representative leans back in his chair, resting uneasily in an awkward silence.
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