300,000 Left Behind

Previously published in 2014.

Medicaid expansion advocates hope that 2015 is the year the Missouri legislature will hear the voices of the 300,000 Missourians who fall into the coverage gap. These people make too much to qualify for Medicaid and too little to qualify for cost-saving subsidies through the federal Health Insurance Marketplace. The Missouri legislature had two opportunities to pass Medicaid expansion and failed to get it done twice.

According to expansion advocates, among many things, lives hang in the balance. “We’ve lost a lot,” said Michelle Trupiano, director of Missouri Medicaid Coalition. “Several studies say that as a result of not passing Medicaid expansion in Missouri, 700 lives have been lost every year. I believe we have lost lives; we have lost quality of life for many people who don’t have access to health care and maybe don’t have access to medication and other services. As a result, they are leading less fulfilling lives because they are too sick.”

Joe Pierle, chief executive officer of the Missouri Primary Care Association, said not passing expansion affects Missouri’s economy. “The bottom line is that health care is an economic engine in almost every community in Missouri. Our failure to move forward with a Medicaid solution is going to put rural and urban health systems at an economic disadvantage to states around us. I’m not an economist, but it’s very simple — states like Iowa, Arkansas and Kentucky, where they showed great leadership and found a solution — health systems in these states are going to be richer.”

But that’s not all. Pierle told accessHealth that Missouri might have another issue: “I wouldn’t be surprised if they try to start [poaching] our providers. Most of Missouri already faces critical provider shortages.”

Jessica Hembree, program and policy officer at the Health Forward Foundation said the “hidden health care tax,” or cost-shifting, is another outcome of not expanding Medicaid. “People who are uninsured are still getting health care, but they are just getting it in ineffective and inefficient ways, like in emergency rooms,” she said. “A lot of those costs are passed on to people with insurance through higher premiums.” Hembree said in the Kansas City area alone, the price tag for cost-shifting is $325 million. For the state as a whole, the price skyrockets to $1 billion. “If we can create more ways to get the uninsured covered, it will stabilize the health insurance market,” she said.

There’s something else to consider. Hospitals and clinics are getting smaller reimbursements for Medicare and Medicaid patients. Medicaid expansion was designed to offset these cuts. Projections don’t look good. For the 24 states that had not expanded Medicaid, 6.7 million residents are projected to remain uninsured in 2016 as a result, according to the Robert Wood Johnson Foundation (RWJF). These states are forfeiting $423.6 billion in federal Medicaid funds from 2013 through 2022. Economists say this will thwart economic activity and job growth. Hospitals in these states are also projected to lose a $167.8 billion (or 31 percent) boost in Medicaid funding that was originally intended to offset major cuts to Medicaid and Medicare reimbursement. Because Medicaid was not expanded in Missouri, these hospitals are taking these cuts on the chin. As for rural hospitals, Pierle said they are getting punched hard.

After two years of advocating for Medicaid expansion in Missouri, where do Missouri voters and legislators stand on the issue? Both Trupiano and Pierle believe we’re still in the education phase. One lesson learned, Trupiano pointed out, is that politicians respond to their constituents. She urges voters to stay vocal about the importance of Medicaid expansion and how it impacts their lives and the lives of their loved ones. “We need to continue to bring everyday ordinary people to the Capitol to talk to their legislators,” she said.

Pierle added that the last legislative session included Republican champions who put political ideology aside and stepped forward. “We intend to work off the momentum we had in the last session to continue to make the case about why this is so important,” he said.

Pierle also urges voters to talk to their representatives and senators about why this is imperative to local communities. “I think it’s time we move past whether you are for Obamacare or against Obamacare to what impact it will have on the local community,” he said. “Somehow, we need to take politics out of this and better understand that decisions have consequences. And these decisions, whatever they are, are going to impact real people.” Arousing Republican voters is one strategy advocates will rely on in the coming months. Trupiano said it’s clear many Republicans see how expanding Medicaid makes for good health care policy and good economic policy. “It just makes good sense all the way around,” she said. “The devil is in the details for a lot of our Republican legislators to make sure that this is a reform bill that works well for all Missourians.”

Turpiano said it’s also important to get in touch with Republican voters to make sure their voices are heard and empower them to speak out about their support for Medicaid expansion that includes reform. “Last year, we came very close and I think it is unfortunate that two or three senators can hold up all of the progress that has been made. So we are continuing to work on those legislators who stand in opposition and have real dialogues about what they need in order to move forward.”

When asked if cost was a viable argument for not expanding Medicaid, Hembree said expansion can happen without breaking the bank. Medicaid expansion was designed to use federal dollars to pay for the lion’s share of health care costs for newly eligible enrollees. Federal dollars would pay 100 percent of the costs from 2014 through 2016. In 2017, the federal government would pay 95 percent of costs, with states on the hook for the remaining 5 percent. In 2018, states would pay 6 percent of costs and in 2019, 7 percent. From 2020 on, a state’s responsibility would cap at 10 percent.

Hembree said the added costs for Missouri would level out as some of the safety net programs it currently pays for, like mental health for instance, would now be covered through the expansion. Additional tax revenue would come to the state through income taxes generated by a more robust health care force.

The numbers alone paint a clear picture. An recent article in the Kansas City Business Journal talks about how for-profit hospitals are faring in states that expanded Medicaid. In short, hospitals saw a decrease in uninsured patients and an increase in Medicaid patients.

A PricewaterhouseCoopers report revealed that HCA “revised its earnings outlook to account for better-than-expected revenue from health reform.” However, the health care system did not disclose actual numbers.

Tenet, a Dallas-based health care system that operates in five states with expanded Medicaid, saw a $78 million reduction in unpaid care in the second quarter alone, according to the report. However, according to the Robert Wood Johnson Foundation, hospitals in non-expansion states are set to lose $167.8 billion in Medicaid revenue between 2013 and 2022. That includes $2.6 billion in Kansas and $6.8 billion in Missouri.

“I anticipate that if we continue to play politics with this issue longer, at the end, everybody is going to hurt,” Pierle said. “Not just people who could have benefited from Medicaid expansion, but everybody in a community who counts on their local hospital, clinic, physician, or nurse is going to feel the impact. There are empty medical offices throughout rural Missouri today…I anticipate that that’s only going to increase the longer we drag our feet.”

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