The plan to expand Medicaid coverage in South Dakota will make a key public appearance Wednesday in the Legislature, where it is given a slim chance of approval this year.
But the future could be brighter for the expansion plan if questions troubling many in the Republican majority about the long-term state costs of expansion can be answered.
That process starts with a 10 a.m. Wednesday joint hearing of the Senate and House Health and Human Services committees. Rep. Scott Munsterman, R-Brookings, who chairs the House committee, said the hearing will begin a public dialogue that will last well beyond this legislative session.
"This year, I would agree that there's a slim chance of it passing," Munsterman said of Medicaid expansion. "But this joint hearing is really the start of us trying to vet this out in the public."
Some of that vetting has already occurred as legislators returned to their home districts for weekends away from the session. Munsterman said many of his constituents share his interest in expanding medical coverage for low-income people but also worry about the long-term budget impacts to the state.
"The feedback I'm getting from people back in Brookings is that they like the idea of helping more people, but at the same time they ask what it means, and where the money would come from," Munsterman said. "And at this point, I can't answer that with any degree of certainty."
There are two key money questions at work: How much of the expansion's costs will the federal government carry long term? Where will the state get its share?
Short term, the federal government would cover everything but $1 million or $2 million in administrative costs, starting in 2014. But that is a gift with a short shelf life. In three years, the state would begin taking on more of the actual expansion costs, up to 10 percent by 2020.
If the bulk of the 48,000 South Dakotans thought to be eligible for the expansion take part, that 10-percent share could mean $40 million to $45 million.
That's financial issue enough. But Munsterman and others fear a bigger bill if federal support shrinks in coming years.
"What I tell people is that once we understand all the financial unknowns, that's when we can have a discussion about our moral obligation and how much it would cost," he said.
Munsterman, a former Brookings mayor and 2010 GOP gubernatorial candidate, said he would welcome that discussion. So would a number of other Republican legislators who are partial to the expansion but fear the cost.
Rep. David Lust of Rapid City, the Republican leader in the House, said support would grow in his caucus if the federal government's commitment to cover 90 percent seemed secure.
"There are some who don't like the expansion of Medicaid, period," Lust said. "I don't think they are the majority. I think the majority believes this has potential but worry about the federal government not being able to uphold its obligation, and what that would mean to us."
Gov. Dennis Daugaard has said he opposes the Medicaid expansion in South Dakota this year but does not necessarily reject it in the future. Lust said many Republican lawmakers feels the same way.
States have the option of expanding Medicaid coverage under the Patient Protection and Affordable Care Act, often called Obamacare.
Lust said not taking that option this session doesn't mean lawmakers won't decide it is worthwhile in the future. And it is not too early to begin a serious discussion about expansion, he said.
Lust worked with House Democratic Leader Bernie Hunhoff of Yankton, a key proponent of the expansion, in forming a group to study the issue. The group decided the expansion would be most appropriately heard before the Health and Humane Service committees.
The joint committees won't vote on the proposal. Its role is to hear from the public in two 40-minute sessions, one each for proponents and opponents. Then committee members will ask questions and discuss the issue.
Munsterman encouraged public comments. He said phone-in accommodations for comments could be made in advance by calling the Legislative Research Council at 605-773-3251.
"We really hope to hear from the people of South Dakota on this," he said. "We don't necessarily need to hear from the lobbyists. We're not discounting what they say. But we hear from them every day."
If lawmakers listen, they'll hear real stories of need and a broad base of public support for the expansion, Hunhoff said.
"We've got 48,000 uninsured. We've got hospital and many rural clinics in dire need of funding," Hunhoff said. "I'm confident that we'll extend Medicaid at some point. The question is when we do it. I don't see any reason to wait."
Any expansion proposal will actually come through the Legislature's Joint Appropriations Committee, where it would be proposed as an amendment to the general appropriations bill. It would then need approval by both the committee and the full House and Senate.
It's an unlikely possibility this year, although Hunhoff isn't giving up on 2013 yet. He believes many of the Republican members who fear the cost in their heads admire the expansion in their hearts.
"Some of them have to play the party line against Obamacare," Hunhoff said. "But I don't think anybody is arguing that a 90-to-10 match from the federal government wouldn't be a great thing for South Dakota. Their real concern is whether we can trust the federal government five or six years down the road to stay with that."