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St. Louis area clinics' program called model for expanded Medicaid under ACA

This article first appeared in th St. Louis Beacon, Sept. 9, 2012 - The Affordable Care Act remains a contentious political issue in Missouri, but St. Louis is already a leader in demonstrating one positive effect of the reform law, according to speaker at a forum Saturday.

Bethany Johnson-Javois, CEO of the St. Louis Integrated Health Network, says St. Louis is giving the public what amounts to a front-row view of how health reform will unfold in 2014 under ACA. She was referring to the federal demonstration grant, called Gateway to Better Health, which is to serve an estimated 30,000 uninsured residents in St. Louis and St. Louis County from now until ACA takes full effect in 2014. The number represents about one-fifth of all of the uninsured in the city and county.

She says the grant is a test of the effectiveness of ACA’s Medicaid expansion model. The goal of the pilot program “partly is to help us understand what will take place hopefully in 2014. St. Louis is now the leader in helping us understand what will happen in the future.”

She was one of four speakers who talked about “demystifying the Affordable Care Act” during a forum on Saturday at Washington Tabernacle Missionary Baptist Church, 3200 Washington Blvd. Joining the church in sponsoring the forum was BJC Healthcare. Other speakers were Robert Hughes, CEO of the Missouri Foundation for Health; Terry Jones, a political science professor at the University of Missouri - St. Louis; and Dr. Michael T. Railey, an associate dean at Saint Louis University.

Johnson-Javois says the pilot already is paying dividends in reaching uninsured residents who lacked easy access to care for treating conditions such as tumors and rheumatoid arthritis. She says the Gateway project is responding to the medically underserved who otherwise were ignoring serious illnesses because they lacked health insurance or money for treatment.

In addition to getting the appropriate medical tests and services from specialists when needed, patients are connected with what’s called a medical home in which they are assigned to a specific primary care doctor. That physician, along with specialists and other providers, keep track of the patients through electronic health records. That means all providers are on the same page in terms of information about the  patient's condition and treatment.

“Without Medicaid expansion, which is what this pilot is,” the newly insured patients would “lose their medical home and their source of specialty care,” she says.

ACA will offer $11 billion in funding through 2015 for community health centers, including $61.2 million for health centers in Missouri. The funding is expected to allow health centers to serve an additional 20 million patients and add an estimated 15,000 providers by 2015.

The bad news, Johnson-Javois says, is the iffy state of Medicaid expansion in Missouri. If lawmakers don’t expand the system as envisioned by ACA, the St. Louis region will have to find an additional $25 million to keep the system going after 2014. The amount is about a quarter of what’s spent on the city-county community health safety net system, which serves about 173,000 patients.

Hughes, the CEO at the Missouri Foundation for Health, says forums like the one Saturday were important even though ACA was approved two years ago.

“Everybody really needs to understand the Affordable Care Act and what’s in it,” he said. “What we’ve learned at the Foundation is that the more we can explain the components, we find that people really like it. So education is an important function and I’m pleased to be part of this.”

Hughes also talked about how the concept of insurance coverage expanded during the World War II era as business used it as a benefit to attract workers. That trend was followed in the 1960s by creation of two patchwork quilt health programs, the federal Medicare system for the elderly and the federal-state Medicaid system for the poor and for nursing home residents. Now, he says the patchwork quilt has holes large enough to leave 1 in 7 Missourians without health insurance.

ACA tries to address that issue through Medicaid expansion for the poor and working poor, and an insurance exchange system to help other individuals and small businesses gain access to affordable health insurance coverage.

Jones, the political science professor, says the health-reform train has been slowed by three developments – federal-state tension that touches on sovereignty issues; rules that have threatened health dollars going to the insurance industry; and a political environment that hasn’t been as polarized as it now is since the Civil War.

Jones says the ideal way to address the health care problem would have been to expand Medicare to cover everyone under age 65. But he said Democrats had to come up with a system that didn’t threaten state government’s role in health care and the existing insurance framework. The insurance exchange system made it possible politically to get the support of health insurance companies and Congress to support ACA.

Ironically, he said, an insurance exchange is a Republican idea but many Republicans balked when Democrats embraced it under ACA. As a result of this partisan divide, Jones says Republicans in several states, including Missouri, are now “engaged in scrimmages, a set of delaying actions. They can’t keep it (an exchange) from happening but they can slow this down.”

He argues that the November ballot initiative regarding health care exchanges is an example. Initially, the wording for the initiative from Missouri Secretary of State Robin Carnahan said, "Shall Missouri law be amended to deny individuals, families and small businesses the ability to access affordable health care plans through a state-based health benefit exchange unless authorized by statute, initiative or referendum or through an exchange operated by the federal government as required by the federal health care act?"

That language was later struck down by Cole County Circuit Judge Daniel Green who ordered the summary to read, “Shall Missouri law be amended to prohibit the governor or any state agency, from establishing or operating state-based health insurance exchanges unless authorized by a vote of the people or by the legislature?” The judge’s order was in line with language favored by Lt. Gov. Peter Kinder and his Republican allies, who had sued, arguing that Carnahan’s summary was biased.

Jones said, “The (Republican) party as constituted will say that Missouri not only didn’t want the exchange process” carried out by “the governor only. They will also say Missouri opposes the whole idea. They are against the Affordable care Act and they will use that as a rallying cry.”

Jones predicts that the effort might slow down a “far a more transparent, more competitive process by which you, I and our employers can buy health insurance. Instead of everybody getting coverage in 2014, as they should be, it’s going to increase the probability of that taking longer.”

June Fowler, a BJC HealthCare vice president who moderated the forum, said there needed to be far more discussion of what ACA means. She say she often hears people say, “I like that. Why didn’t I know that?” Those are responses that come only after “people see what’s in the law, when they realize that their kids can stay on their insurance until they are age 26, that almost $1 billion in rebates have come from insurance companies that are now required to spend 80 percent of premiums on health care services, when they realize you’re no longer denied coverage because you have a pre-existing condition.”

Some questions in the audience showed deep concerns about the health reform law. One man’s concern, for example, was whether police would step in and arrest him if he didn’t buy health insurance. He was told the health care law prohibits that type of treatment. A more likely possibility, he was told, was that the IRS might be required to add the cost of coverage to his tax bill.

The health reform law offers mixed benefits to physicians, according to SLU’s Dr. Railey, who said students were concerned about how changes in ACA would affect their ability to cover their medical school debt.

He mentions speaking with a former SLU graduate now at the University of Kansas. “I asked her how much debt she had, and it was over $300,000. That is before your first house, before buying your first car. You have an economy that’s forcing doctors to wonder how long it will take to pay off the loans and if they can’t pay their loans, what kind of life is it going to be?”

These students are simply saying, “I want the life I looked forward to when I took this on.” He said the dilemma “is a terrible thing. It is forcing a lot of young people to say they want to pick a profession that gives them the best return.” In some instances, that means choosing a high-income medical specialty rather than primary care, which tends to pay less. Primary care also happens to be the area where doctors are needed most under ACA.

On the other hand, he says he encourages student to remain true to service as physicians. Citing doctors who make a commitment to care for Medicaid patients even if the fees are very low, Railey says, “That’s the kind of doctor I want ... someone who would take care of patients regardless.”

Railey supports ACA. He cautioned the audience about people who portray it as a program for those undeserving of care.

Opponents to ACA largely have avoided demonizing recipients. But they have expressed concern about the nation's deficit and the cost of health reform. They also express concern that Missouri cannot afford the long-term cost of expanding the Medicaid program.

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.