The clock is ticking on Missouri legislators to expand Medicaid

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JEFFERSON CITY - Linda Spence is a 63-year-old full-time student at University of Missouri-Kansas City. After losing her job as a Program Director on the campus of UMKC, she has no health insurance because she does not qualify for Medicaid.

After the US Supreme Court ruled it unconstitutional for the federal government to force states into expanding their Medicaid coverage, Missouri now has a choice of whether or not to expand Medicaid for people like Linda Spence.

The Federal government will pay 100 percent of the financial burden imposed by Medicaid expansion for the first three years, but starting after the initial grace period, Missouri would start to become responsible for some of the cost. Starting in 2017, Missouri would be responsible for five percent of the cost in 2017 and 10 percent starting in 2022, according to state officials and advocacy groups.

Spence said she takes advantage of a discount at Truman Hospital for people with lower incomes. She said not many people know about this discount, and people who want it must apply for it. Spence also said without this discount, she would have no way of obtaining any kind of regular health care. She also said that not having insurance can affect the quality of health care she is able to receive.

"If I were able to qualify for something like Medicaid, granted I would have to qualify for it, but at least I would know it was something a little bit more guaranteed. I might have access to other physicians other than going through Truman. Maybe I would be able to choose my own doctor, for example. Go to specialists of my choosing, instead of just specialist that are available," said Spence.

A major concern legislators have with expansion is that it could take away a lot of funding from other areas of the budget, namely education.

"When you're looking at increases of potentially 100 or 200 million dollars that you have to find because of expansion, there is only one place where there is a pot of money big enough to take that, and that is public education," said Senate Appropriations Chair Kurt Schaefer, R-Columbia.

Schaefer said that there is no way around public education funding taking a hit with the Medicaid expansion, and if the true cost, is too detrimental to education then he would not be in favor of expansion.

Sen. Rob Schaaf, R-St. Joseph, thinks Missouri would have to pull funds from a diverse group of areas to fund expansion.

"I know from my experience as a legislator, that anytime one program absorbs up a bunch of resources, they try to spread the pain around everywhere else. So it isn't just education, every other program would suffer," Schaaf said.

Schaaf said Missouri does not have an obligation to use tax dollars to give able-bodied adults health care.

"We already take care of kids, and we take care of the disabled, and we take care of the elderly. These people are able-bodied, and it would be wrong for us to give them free health care and put them on Medicaid, and expect other working adults to pay for them," Schaaf, a licensed physician, said.

For a single parent with one child to receive Medicaid under the current coverage in Missouri, their annual income would need to be less than $2,809.00, according to the Missouri Foundation for Health. The new program, should it be implemented in Missouri, would allow anyone at 133 percent of the federal poverty line to receive Medicaid. That covers a higher percentage of the poverty line than is currently afforded to people who are blind in Missouri.

"Those single people, who are not on their parents insurance, and are not yet 65 are just...out of luck," Spence said.

Group Covered	Federal Poverty Level Requirement
Children (age 1-19)	Under 300%
Pregnant Women	Under 185%
Blind	Under 100%
Qualified Medicare Beneficiaries	Under 100%
Elderly (over 65)	Under 85%
Disabled	Under 85%
Parents	Under 18%

source: Missouri Foundation for Health

One of the problems a large uninsured population poses is the hidden cost they impose on people who do have insurance. Emergency rooms cannot turn people with a legitimate medical emergency away.

"It's estimated that $1000 to $1200 of people's yearly insurance premiums goes to paying the cost of the uninsured," said Andrea Routh, Executive Director of the Missouri Health Advocacy Alliance, a non-profit group whose goal is to find affordable health care for all of Missouri.

Dave Dillon, Missouri Hospital Association spokesman calls this the hidden cost of the uninsured.

"I think there's an argument to be made for pretty much everyone in the state that paying that toll in the long term doesn't make as much sense as trying to find ways to reduce the number of uninsured," Dillon said.

Spence made clear that going on Medicaid and receiving benefits from tax dollars is not a goal for people in her position.

"I'm used to being independent. Most people want to be on their own. Most people don't want to have to depend on entitlement programs," Spence said.

The state currently receives funds from the federal government that helps pay the cost of the uninsured. Routh said Hospitals agreed to receive less of these funds under the Affordable Care Act, expecting to receive funding for Medicaid that would include many of the previously uninsured patients.

Routh said many rural hospitals risk going out of business if the state does not expand. She thinks the loss of funds would be too great to overcome. This is not only problematic because of the job losses these rural cities would sustain, but also because people would need to travel much farther to get to a hospital if they lived in one of these areas.

Schaefer said the hospitals not only lose funding for uninsured, but also funding for Medicare under the Affordable Care Act, causing a serious likelihood of rural hospitals going out of business.

Routh said Missouri would be a big winner in the Affordable Care Act if it chose to expand because the current coverage is so far below the proposed coverage that it would get a lot more money from the federal government than other states that already cover more people on Medicaid.

"That's a lot of money. It represents something like three point six percent of our gross state product, so when you talk about those kinds of infusion of investment... a lot of people could be put to work if we actually cover these folks under Medicaid," Routh said.

According to Urban Institute's estimates using 2010 American Community Survey, Missouri has the seventh highest "share of uninsured potentially Medicaid eligible" in the United States at 58 percent. The survey also showed that 452,000 Missourians are under 138 percent of the Federal Poverty Line.

Lawmakers do not have to make a final decision on expansion this year, but time is running out for Missouri to figure out what to do about people like Linda Spence.