What can Missouri learn from other states that have expanded Medicaid?

Jul. 29--Arkansas became the first Republican-leaning state to adopt Medicaid expansion in 2014, and the impact was swift and undeniable.

In the first year under expansion, the state's uninsured population was effectively halved, from 22.5% to 11.4%, according to a 2015 Gallup report.

Six years later, Missouri remains one of just 13 states that has not expanded its Medicaid program as provided for under the Affordable Care Act.

A proposed constitutional amendment on the Aug. 4 ballot could change that. If approved, expansion would provide coverage for an estimated 300,000 low-income Missourians with annual incomes up to 138% of the federal poverty level -- currently $17,608 for an individual.

According to research by the nonpartisan Kaiser Family Foundation, Medicaid expansion has "improved access to care, utilization of services, the affordability of care, and financial security among the low-income population."

"Studies show that Medicaid expansions result in reductions in uncompensated care costs for hospitals and clinics, and a growing number of studies show an association between expansion and gains in employment as well as growth in the labor market," the Kaiser analysis concluded.

Uncompensated care, or care for the uninsured, has been a significant strain on struggling rural hospitals -- 10 of which have closed in Missouri since Medicaid expansion became an option. By contrast, just one rural hospital has closed in Arkansas since 2014.

Still, conservatives argue that expansion will cost the state money, likely necessitating cuts to education and other state programs

.St. Charles County Sen. Bill Eigel said that before considering expansion, Missouri should fix its current Medicaid program, which he characterized as bloated and wasteful.

"When you have a program that's run as inefficiently and poorly as our current Medicaid program, the last thing you want to do is make it bigger," Eigel said.

The federal government initially paid 100% of states' expansion costs, and now pays 90%. A Commonwealth Foundation study found that the actual net price of expansion for states is well below the "sticker price" of 10%. In some cases, the net cost is negative, because of other spending cuts expansion makes possible.

A 2019 study from the Washington University's Center for Health Economics and Policy concluded that Medicaid expansion in Missouri "is close to budget neutrality and actually has an estimated savings of $39 million."

Advocates are selling expansion not just as a lifeline for low-income residents but as an economic development opportunity.

The Missouri Foundation for Health says expansion would bolster the state economy and create 16,330 jobs, which prompted the reliably conservative Missouri Chamber of Commerce and Industry to endorse the ballot initiative.

But Eigel was critical of these sunny economic projections.

"You can't advocate for economic growth through government expansion. That's the antithesis of what this country was founded on," he said.

Earlier this month, Oklahoma became the fifth Republican-leaning state to endorse Medicaid expansion through a referendum vote, circumventing the will of conservative politicians.

President Trump campaigned on the message of repealing and replacing the Affordable Care Act, but Republican efforts to do so stalled out in 2017. The administration is now asking the Supreme Court to invalidate the landmark legislation.

The coverage gap

It's a misconception that the only the poorest of the poor stand to benefit from Medicaid expansion. It would provide coverage for those who find themselves in an economic gap -- unable to afford healthcare or qualify for Medicaid benefits.

One such person is Catina Taylor, a 48-year-old Kansas City native who lost coverage when she pursued a new career path.

After earning her law degree from the University of Kansas, Taylor decided against going into law. Instead, she became a teacher, spending 15 years in the Kansas City public school system before starting her own small business.

Taylor founded DREAMS Consulting, which provides education, business and legal consulting. She was excited to pursue the new venture, which combined her areas of passion and expertise. There was just one drawback.

"When I left the classroom, of course that means I lost insurance coverage," Taylor said.

She looked into a government healthcare plan, but couldn't afford it. As an adult with no dependent children, she didn't qualify for Medicaid either.

And just like that, Taylor fell into the coverage gap.

"I think that people have an idea or a thought when we talk about Medicaid expansion that it's the most poor among us or the most destitute," Taylor said. "They don't see a person who has a law degree. They don't see an entrepreneur like me who has worked since I was 15 years old, and here I am."

But Sen. Eigel sees it differently. He said Medicaid coverage isn't intended for "able-bodied" adults, who might develop a dependency on government healthcare.

"We're already covering the folks that are the most needy in the state," Eigel said.

"Government has a responsibility to help those less fortunate, but at the same time, we can't expand unlimited amounts of dollars [for people] that quite frankly don't need the help in the first place."

Taylor said she's only had one medical emergency over the last five years, but the unexpected ambulance trip to the emergency room set her back $10,000.

"You think about all of the associated bills with that, and now I have them and I'm in debt, so I'm trying to claw my way out of that as an uninsured person," Taylor said.

Tension over work requirements

Some states have pushed in recent years to make work compulsory for many Medicaid recipients. Like Taylor, 65% of people who fall into the coverage gap are already working, according to the Urban Institute.

In January 2018, under the Trump administration's direction, the Centers for Medicare & Medicaid Services issued a new policy allowing states to implement work and community engagement requirements for non-elderly, non-pregnant and non-disabled adult Medicaid enrollees.

In February, a court threw out Arkansas' 80-hour-a-month work requirement after more than 18,000 Medicaid recipients were disenrolled within six months of implementation.

Voters in Utah and Idaho approved Medicaid expansion referendums in 2018, but legislators in both states added conditions modifying expansion, including work requirements in Utah. The state voluntarily suspended these requirements in April due to COVID-19.

Missouri did not submit a work requirement waiver application, and if Medicaid expansion passes, legislators likely won't be able to tack on work requirements for the expansion population. That's because Missouri's ballot measure guards against such stipulations.

"This amendment prohibits placing greater or additional burdens on eligibility or enrollment standards, methodologies or practices on persons covered under Medicaid Expansion than on any other population eligible for Medicaid," a portion of the measure reads.

Anita Cardwell, senior policy associate at the National Academy for State Health Policy, said recent legislative battles over approved referendums likely served as an example of what to avoid for expansion advocates.

"Utah in particular, voters voted for traditional expansion but there were significant changes," Cardwell said.

"The advocates for expansion, perhaps because of what happened in Utah and Idaho, they decided to take the strategy of, 'We're going to craft the ballot language so that state legislatures cannot change the expansion model."

Oklahoma's approved constitutional amendment was similarly worded, undermining Republican Gov. Kevin Stitt's plan to pursue an alternative method of expansion that, by the state's own admission, would likely depress the program's enrollment by 5% compared to traditional expansion.

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