Lincoln Sen. Kathy Campbell started Nebraska's debate Tuesday morning with a letter she received from a quadriplegic constituent.

Too many working people in Nebraska don't have health insurance because they make too much money to qualify for Medicaid but too little to afford private insurance premiums, the constituent said. 

The person, who works part time and requires daily home health care to maintain independence, is one of those people.

"There is really, at some point I wonder, no incentive for me to work," Campbell read.

Debate on a bill (LB577) that would expand Medicaid to potentially cover an estimated 54,000 more state residents went on a little more than five hours Tuesday and will continue Wednesday.

Senators adopted the first half of the Health and Human Services Committee amendment to the bill, which was divided by request of Omaha Sen. Beau McCoy.

They voted 30-12 after a couple of hours of debate to allow a review by the Legislature if the federal payment for Medicaid expansion falls below 90 percent for the Medicaid adult group described in the bill. The Legislature would be able to affirm, amend or repeal the eligibility of the group, or take action allowed under the medical assistance program to reduce state expenditures.

But McCoy moved to reconsider that vote, saying there had not been enough debate. That discussion continued until the Legislature adjourned for the day.

In 2009, the Legislature spent almost two weeks of half-day sessions on roadside trapping, McCoy said.

"We spent more time over live traps versus dead traps, over one-legged traps versus full-body traps, snares, than we just spent on speaking to a federal match for the biggest portion of our state budget," he said. "That's just not right."

Medicaid is based on income and is available to low-income children, a limited number of poor parents, pregnant women, elderly and blind people, and those with disabilities. The expansion would add low-income, uninsured, childless adults, ages 19 to 65, who fall between 0 and 133 percent of the federal poverty level. It also would cover some additional low-income parents.

Beatty Brasch, director of Lincoln's Center for People in Need, said in an email the need for Medicaid expansion was apparent in Lincoln.

The center’s December 2012 Face of Poverty survey revealed that of 1,801 clients surveyed -- most of whom had an employed adult in the household -- 43 percent had no health insurance and 37 percent had not seen a doctor when needed because they couldn't pay for it.

Thirty-four percent had gone to an emergency room in the past year because they had no money to pay for an office visit. Forty-one percent had taken less of a prescribed medication to make it last longer, and 56 percent had gone without prescriptions altogether.

LB577 can address those needs, Brasch said.

Campbell said the federal share of an estimated $2.3 billion in tax dollars over the next seven years could come back to Nebraska.

"Some say, 'Well, it will come down to money.' But I've learned that for every dollar figure in a budget book, it really comes down to people."

In the early hours of debate Tuesday, Sen. Bill Kintner of Papillion said Medicaid was way beyond what anyone in 1965 thought it would be.

"Matter of fact, if the Congress in 1965 saw what Medicaid had become, I don't think they would even vote for it," he said.

Like Ronald Reagan, Kintner said, he believes the best government program is a job.

"I would much rather lift people up, give them economic opportunity, give them a job, not give them a way to muddle around in their life, going paycheck to paycheck."

Sen. Mike Gloor of Grand Island said he was skeptical of passing Medicaid expansion. The health care system is complex and operates in ways contrary to typical and common-sense business practice, he said.

"To manage and control this system in its entirety is not possible," Gloor said.

"The assumption that expanding Medicaid coverage automatically provides equal access and improves quality care is a hope and a prayer."

Omaha Sen. Jeremy Nordquist said access to health coverage for all Nebraska citizens is a goal the state should pursue. But the question should be how to pay for it.

"The most direct answer and the most correct answer is that we already do," Nordquist said."We have a cobbled-together safety net funded with state general funds that unfortunately catch people at the costly deep end of care rather than catching them at the preventative primary health care."

LB577 could reorient the dollars the state, counties and those who have private insurance already are spending on programs to get people primary, preventive care, he said. It can be done without raising taxes and without making cuts to other important government programs.

The revised fiscal note shows that the bill would save general fund dollars during the next four fiscal years, 2013-17. From 2017-20, the cost of expansion would be about $60 million in state general funds.

On Wednesday, senators are likely to debate the second half of the amendment, deciding whether Medicaid expansion should end in 2020.

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