For months, I’ve been wondering if and when some Republican lawmakers would balk at supporting Governor Terry Branstad’s “costs more, covers less” alternative to expanding Medicaid in Iowa.

For the first time yesterday, an Iowa House Republican said he may not vote for Branstad’s plan. I doubt it’s a coincidence that the wavering lawmaker is unusually knowledgeable about health care services in Iowa.

A bill outlining Branstad’s Healthy Iowa Plan arrived at the legislature a few weeks ago. Yesterday Iowa House Appropriations Committee voted on party lines to send it to the full chamber. Jason Noble reported for the Des Moines Register that State Representative Dave Heaton “offered unusually blunt criticism” of the plan.

Heaton, the chairman of the House Health and Human Services Appropriations Subcommittee from Mount Pleasant, questioned whether a federal marketplace for private insurance that is a key component of the plan would be available for use by enrollees, doubted whether the proposal could pass muster with the federal agency that would provide much of its funding and worried that the plan would raid local property tax dollars needed for mental health services.

“This is the most significant vote that I will have made in the 20 years that I’ve been here,” he predicted. He added, “At this present time I don’t know how I’m going to vote.”

Heaton supported advancing the bill out of the House Appropriations Committee on Monday out of loyalty to his GOP caucus, but said when the bill comes up on the floor, “it’s a whole ‘nother ballgame.” […]

He noted in particular that eligibility for the program could be capped if federal funds aren’t available. The feds will never agree to such a restriction, he said.

Heaton has chaired the House Health and Human Services Appropriations Subcommittee since Republicans regained the House majority for the 2011 legislative session. He’s probably forgotten more about health care delivery in Iowa than this bill’s floor manager Walt Rogers will ever know.

Not only does Heaton know more about this subject than most of his GOP colleagues, he has served in the Iowa House since 1994. Only one of the 53 House Republicans (Jack Drake) has more legislative experience.

Heaton isn’t afraid to rock the boat; earlier this year, he questioned the Branstad administration’s policy on driver’s license for some undocumented immigrants. His comments helped generate momentum for reversing that policy.

Heaton didn’t say yesterday that he will vote against the Healthy Iowa Plan on the House floor, but if he does, it would take only two other Republican doubters to keep the alternative to Medicaid expansion from passing.

House leaders will presumably twist Heaton’s arm to bring him around before the bill comes to a vote. They might point out that the plan could be improved in a conference committee after the Iowa Senate rejects the House version. All 26 Iowa Senate Democrats are committed to expanding Medicaid, as foreseen in the 2010 federal health care reform law.

It would be smarter for a few House Republicans to join Democrats in rejecting this bill. Spencer Hospital President Bill Bumgarner wrote in a guest editorial for the Spencer Daily Reporter,

Governor Terry Branstad’s proposed Healthy Iowa Plan – while well intended – is not practical and reflects a misunderstanding of health care access challenges in rural Iowa. Most notably, Iowans who are part of this newly covered population may not be able to use local hospitals and physicians. It would also be more costly to the State of Iowa by not maximizing the availability of federal government dollars over the next five years. Our first objective should be to provide increased access to care before considering the more complex health improvement initiatives proposed by the governor. […]

A decision against extending Medicaid coverage to more Iowans also could have a financial impact on health care providers. Spencer Hospital and other Iowa health care providers already serve those who would benefit from Medicaid expansion when they become so sick they need care in our emergency departments – and we absorb those costs as unreimbursed charity care. This too reflects the hospital’s mission, but the rate of growth for charity care is unsustainable and undermines our ability to support the overall demand not only for hospital services, but for other community-benefiting programs that, frankly, only our organization can provide.

More importantly, the emergency department is no replacement for a personal physician. Expanding Medicaid will improve access to primary care providers and begin the process of driving down costs by offering care earlier after a health condition arises rather than delaying treatment until it becomes more serious — and more expensive – to treat. […]

If Iowa legislators decide against Medicaid expansion and support the alternative Healthy Iowa Plan, we will be left with the worst of both worlds: providing more uncompensated care for Iowans still not eligible for Medicaid while receiving less money from the federal government to cover these costs.

“Accountability” and “outcome-based solutions” have been key Republican buzzwords during the Medicaid debate this year. Cancer specialist Dr. Richard Deming pointed out in recent testimony to Iowa lawmakers,

I’m in favor of patient accountability, but before we can have accountability, we need access.  Without access, there is no opportunity for accountability.

Each and every day I see individuals who do not have insurance who present with advanced cancer because they put off seeking medical attention until it’s too late. Without access, individuals do not get preventive services, do not get early detection screenings and do not obtain services when cancer is in an early stage.

Eventually they become ill as their cancer progresses and eventually they ask for help and eventually they come to see me with advanced cancer.  At that point, it’s often too late to be able to cure their cancer.

For me, this debate is not primarily about the finances and it’s certainly not about my pocketbook.  It’s about human dignity and social justice.  I have never ever turned down a patient because he or she wasn’t able to pay.  I never will, regardless of how this vote goes.

But if individuals don’t have access, they won’t attempt to obtain prevention and early detection.  They will come to me for free care when I can no longer cure them of their cancer because it is too advanced. […]

I agree with the governor that we need to reform health care and make it more accountable.  We at Mercy are “all in” when it comes to accountable care.  We have already developed an accountable care plan for our own employees.  We have developed an accountable care plan for our Medicare patients and we have developed an accountable care plan for a segment of our privately insured patients.  We have already had a meeting with the Medicaid office to discuss developing accountable care around Medicaid.

Iowa needs to work with the federal government to develop a plan to provide accountable care for the Medicaid population. But this can be done through Medicaid expansion.

Governor Branstad and Iowa legislators, I promise you this:

If we expand Medicaid, Mercy will work with you and the Medicaid program to help develop a system of accountable care for Medicaid patients.  I will personally work with you to help bring health systems and physicians to the table to work on an innovative way for Iowa to create accountable care for our Medicaid enrollees.  As I said, we are already doing it for Medicare, we are doing it for our employees, we are doing it for some of our privately insured – and we can do it for Medicaid.

Heaton should recruit two other brave Iowa House Republicans to reject Branstad’s alternative. Then the focus of the debate can shift to improving Medicaid as we expand the program to cover more indigent Iowans.