U.S. Sen. Claire McCaskill, D-Mo., lamented Thursday that state officials in Jefferson City may avoid setting up a health insurance exchange or expanding the Medicaid rolls, as called for in the federal Affordable Care Act.

While emphasizing that “it’s not a decision I can or should make,” McCaskill told reporters during a campaign stop in St. Charles that “it would be unfortunate for federal tax dollars to go to help states around the country, but not Missourians.”

“I think it would be mistake for Missouri officials to turn up their noses at a Medicaid expansion that is fully paid for by their federal tax dollars,” she added. “A little like cutting off your nose to spite your face.”

McCaskill, a former state auditor and state legislator, was reacting to reports that Missouri Republican legislative leaders are solid in their opposition to Medicaid expansion or creating an exchange.

The Affordable Care Act calls for the federal government to pay all the costs for the first three years of the Medicaid expansion, and no less than 90 percent after that. The exchanges are designed to allow people without job-provided health insurance to buy it on their own at a cheaper price.

Both programs are to be in place by 2014.

Republicans say even the state’s 10 percent share would be too costly for Missouri. They also are wary of the exchange program, and want to wait at least until after the November election before any action is taken.

The federal government can set up an exchange for Missouri, if the state does not. But a measure will be on Missouri's ballot that will bar the creation of an exchange without the approval of the General Assembly or Missouri voters.

Republicans also contend that the federal government can’t afford to spend more money on health care, when the federal debt continues to increase.

McCaskill declined comment on why Gov. Jay Nixon, a fellow Democrat, has yet to discuss the issue. But overall, she said she was mystified by the controversy.

“Paying 10 cents on the dollar to make sure that hundreds of thousands of Missourians have access to health care other than the emergency room is going to keep health care costs down for everybody,” she said. “People who show up at the emergency room without health insurance and don’t qualify for Medicaid, we’re paying those bills. There’s not a fairy that goes around and makes those bills disappear.”

McCaskill also disputed the GOP assertion that the federal government can’t afford to spend more money on health care, when the federal debt continues to increase. “The Congressional Budget Office has scored it as a deficit-reduction bill,” she said.

McCaskill’s comments were in line with her recent outspoken defense of the Affordable Care Act, after initially saying little following last week’s Supreme Court decision that largely left the measure intact.

McCaskill contended Thursday that she and other Democrats are seeking to put out the facts about the act and that she hoped Missourians would listen.

“The Republicans are busy lying about it,” she said. “There are so many distortions and lies being told about this legislation, it’s frankly jaw-dropping.”

Opposes privatizing Social Security, Medicare, student loans

Even so, the Affordable Care Act is not McCaskill’s top campaign issue as she seeks to frame the debate with her three best-known Republican opponents: St. Louis businessman John Brunner, former state Treasurer Sarah Steelman and U.S. Rep. Todd Akin, R-Wildwood.

McCaskill told close to 100 supporters who braved the heat to show up at the formal opening of her St. Charles office that they should focus on three issues as they campaigned for her re-election.

The “Big Three,” as she dubbed them, were her opponents’ efforts to:

• “Privatize Medicare. They want to give seniors a certain amount of money … and they are on their own.”
• “Privatize Social Security,” which she alleged could lead to people losing all their retirement savings in the stock market. “What if they invested in one of these firms that went bust on Wall Street?” she asked.
• “Privatize student loans,” which she said would result in only children from wealthy families qualifying for student loans.

McCaskill cited her own middle-class background. “I wouldn’t be a lawyer if not for the fact that there were student loans,” the senator said.

Overall, she asserted, "These three candidates make John Ashcroft look like a liberal."

Brunner, Akin and Steelman are expected to reinforce their views at their next debate, slated for Friday at Washington University. The event is hosted by KMOV-TV (Channel 4).

McCaskill was introduced by Missouri Attorney General Chris Koster, a Republican-turned-Democrat who – like McCaskill – is a former county prosecutor. Both of them broke into politics in western Missouri.

Koster's presence appeared aimed at reinforcing McCaskill's portrayal of herself as an independent and moderate.

Koster praised the senator and, among things, cited the battle over the Affordable Care Act. The audience cheered as he declared, “The discussion of health care in this country has moved forward for the first time in 70 years.”

St. Louis County likely the November deal-breaker

(Start of update) Later Thursday, McCaskill greeted a crowd packed into a campaign office in Warson Woods that will be jointly operated with national Democrats campaigning for President Barack Obama.

McCaskill was joined by St. Louis County Executive Charlie Dooley, who loudly declared that the senator needs to attract as many county votes as possible.

He noted that in 2006,  McCaskill's 51,000-edge in St. Louis County was more than her 49,000 edge statewide.

Dooley and McCaskill emphasized that she can't win re-election this fall without a strong showing among St. Louis County voters. (End of update)