This article first appeared in the St. Louis Beacon, Oct. 3, 2012 - Angela Pace gave up on getting $1,600 worth of medicine to shrink a tumor after she discovered that her insurer required her to cover 75 percent of the cost.
Her problem isn’t as costly as Mark Hoggard’s. He’s uninsured and is trying to figure out how he will ever cover the $85,000 bill for his open-heart surgery last fall.
The two regard the proposed Medicaid expansion as one way to bring relief to working poor like themselves. In the meantime, they take solace in the fact that some of their other health needs are met through a highly regarded, virtually free clinic, the Community Health in Partnership Services or CHIPS, at 2431 North Grand Blvd.
Whether Medicaid should be expanded to cover the near poor continues to be widely discussed in every state, with GOP leadership in some states, such as Missouri, reluctant to expand the program, while Democrats in states like Illinois are embracing the Medicaid changes. The issue is likely to get an airing during the health-care half of tonight’s presidential debate.
Some people may be surprised at how their state spends most of its funding for Medicaid, a program that’s often discussed but not always understood. The basic program in Missouri serves more than 1 million residents, with families and children making up 73 percent of enrollees, who consume only about 34 percent of the resources. The elderly and disabled make up the remaining 27 percent of participants, but they account for 66 percent of the program’s spending.
In the 2011 fiscal year, federal funding covered slightly more than 51 percent of Missouri’s Medicaid budget of $6.6 billion. General revenue covered only about 16 percent, with the remaining 33 percent coming from a variety of sources, including federal reimbursements to hospitals that treat the needy and taxes.
Some hospitals in Missouri are particularly concerned about the debate over expanding Medicaid. They receive a Medicaid reimbursement for treating a disproportionate share of poor patients with special needs, reaching $1.3 billion in the 2011 fiscal year. This allowance is discontinued under the Affordable Care Act because it is assumed that more people will have health insurance, making additional reimbursements to hospitals for treating a higher than average share of poor patients unnecessary. Missouri hospitals haven’t said what they would do if the state does not expand Medicaid and the number of underinsured and uninsured residents remains high.
The combination of Medicaid expansion and an insurance exchange system is projected to extend coverage to more than 509,000 currently uninsured Missourians. Even so, another 255,000 still would be without insurance. Margie Diekemper, health services director at CHIPS, says those left behind underscore the need for organizations like CHIPS.
“We are hoping that CHIPS will be around to serve some of those still without health insurance,” she says. Patients who use CHIPS pay a $25 annual fee and are served by one of 19 volunteer doctors. CHIPS gets its operating money from foundations, corporate sponsors, private donors and grants, and it serves patients from Missouri and Illinois.
“The future of health care is a huge issue,” says Hoggard, 44, the open-heart surgery patient who lives in Columbia, Ill. “But I can’t tell you enough about the good treatment that I get from the (CHIPS) staff. I’ve told them that without CHIPS, I’d probably be dead.” He had health insurance when he worked as a sandblaster and painter. But he says premiums were so high that he could not afford to keep the coverage. Still uninsured, he now does custodial work at an assisted living facility in the Metro East.
Similar praise for CHIPS comes from Pace, 47, of Florissant, the patient who was coping with a tumor. She now works door to door for a company that helps Illinois residents lower their electric bill under deregulation. She couldn’t afford health insurance and was at a loss until she heard about CHIPS.
“The staff treats you with respect,” she says, adding that it’s not unusual to see CHIPS President and CEO Judy Bentley “in the hall, greeting patients and treating everybody with dignity.”
While a lot has been done on the health insurance front nationally, and the state administration in Missouri has done a lot of internal work, many ACA issues over which Missouri has control are at a virtual standstill, says Timothy McBride, a professor at the Brown School of Social Work at Washington University. Examples are GOP decisions not to pursue Medicaid expansion, accept federal money for computer upgrades or create a state insurance exchange.
Still, McBride and Sidney Watson, a law professor at St. Louis University, point to some changes that bode well for health reform. They point to census data showing that the percentage of Americans without health insurance dropped to 15.7 percent last year, compared to 16.3 percent in 2010. In addition, they note that other national data show slower growth in health insurance premiums, which rose 4 percent this year. That’s news because premiums have risen quite sharply since 2002, according to the Commonwealth Fund.
But the good news hasn’t made Medicaid’s future any brighter. Everybody agrees that cost remains a major concern, with many states saying they can’t afford to expand Medicaid even if the federal government covers the entire cost for the first few years. As for Medicare, which has about 975,000 enrollees in Missouri, the big cost concern is that baby boomers now enrolling are driving up the program’s cost.
“We need to come to some kind of agreement of what these programs are about,” Susan Feigenbaum, an economist at the University of Missouri at Saint Louis, says of Medicaid and Medicare spending. “Are they an entitlement for everyone? Are they are safety net, and if so, do they need to be means-tested, not just in terms of income but in terms of wealth and holdings?”
She says one way to address Medicaid costs would be to “give each state a block grant equal to the amount of subsidy that you think ought to be in the safety net and let states figure out what they want to do.”
Watson, the SLU law professor, has a different view. She says it makes sense for states to invest in Medicaid. “The next big policy question will be whether Missouri will expand the program to cover everyone up to 133 percent of the poverty level,” meaning $14,856 for a single-person household.
“Without Medicaid expansion, Missourians who work in jobs at retail stores, restaurants, fast food stores and landscaping won’t have a source of affordable health insurance,” she says. She calls the expansion “part of building an infrastructure. That’s an investment we make in each other. It makes us a stronger country, gives us a better workforce, and creates incentives to work. I don’t know how we can’t afford to do it.”
One often overlooked issue in projecting the value of health reform, says UMSL’s Feigenbaum, is the notion that American health policy and costs should compare to other Western nations, such as Sweden. A valid comparison, she says, would require controlling for “whatever makes us different demographically,” such as (rates of) teen pregnancy, trauma, HIV, drug use and crime related to drug use.
“Once you control for a lot of these things, our health expenditures are not so far out of line,” she argues. “Guess what? Sweden doesn’t have an underclass with drugs and with crime. It doesn’t have a lot of teen pregnancy. Everybody is sort of like each other there. Income levels are higher, they eat better; there isn’t as much obesity.”
As soon as ACA became law, Joe Pierle, CEO of the Missouri Primary Care Association, began to wonder where states would find enough primary care doctors to treat the newly insured?
“Nothing is being done about the shortage,” he says. “I think the biggest threat to ACA isn’t the political process but not having enough primary care providers to meet the demand.”
Dr. Kate Lichtenberg, a family physician and president of the Missouri Academy of Family Physicians, says the profession wasn’t caught off guard on this issue.
“We knew we didn’t have enough. It’s something that primary care organizations have struggled with because it takes so long to produce just a single family doctor. A lot of people are going to get health insurance as ACA is rolled in, but it doesn’t mean they will have access to care.”
