The four Republican candidates for Missouri governor kicked off their debate Wednesday night with a variety of statements about the Affordable Care Act and Medicaid expansion. KCUR fact-checked some of those statements. Here’s what we found:
“Obamacare has failed in every regard. We were told it was going to reduce premiums. On average, premiums went up for the exchange in Missouri over 23 percent last year.”
The number Hanaway cited comes from the Koch-backed Freedom Partners, an organization that opposes the Affordable Care Act, or Obamacare, and Medicaid expansion. In fact, benchmark premiums – the second-lowest-cost silver plan – went up an average of 10.4 percent in Missouri this year, according to the Centers for Medicare and Medicaid Services (CMS).
Because Missouri currently does not require health insurers to file proposed rates with the Missouri Department of Insurance (a new law does require them to do so, beginning in 2018), it was unable to provide KCUR with an overall average.
But what’s important to note is that 87 percent of Missourians who signed up for individual plans through the Affordable Care Act exchange received premium subsidies. In 2016, the average pre-subsidy premium was $407 per month, but for those receiving subsidies, the average post-subsidy premium was just $94 a month, according to healthinsurance.org, a respected, independent website that tracks the ACA's implementation.
“Four million people lost health insurance last year.”
KCUR reached out to the Hanaway campaign to see if she was referring to Missouri or the nation as a whole. One of her staffers forwarded a link to this 2013 Associated Press article, which says 4.7 million Americans received notices that their current health insurance policies did not meet minimum requirements outlined in the Affordable Care Act. Factcheck.org actually tackled this one in 2014, saying that the AP’s estimate was likely inflated and a better number was 2.6 million.
So did 2.6 million people lose their insurance? Nope. In fact, many of them likely went on to buy insurance through the exchanges – by mid-March 2014, there was a net gain of 9.3 million American adults who had insurance. Interestingly, the very article the Hanaway camp sent to KCUR actually notes that in Missouri, insurers were allowed to continue offering canceled policies.
The Missouri Department of Insurance says the uninsured rate in the state has fallen from 15.3 percent in 2009, before Obamacare, to 8.8 percent in 2014 (the most recent year for which figures are available), after Obamacare took effect.
“In fact, the biggest insurer in Missouri – one of the two biggest – has recently pulled out.”
In April, UnitedHealth Group, the nation’s largest health insurer, said it would stop offering exchange plans in 2017 in Missouri and all but a handful of the other 33 states where it offered exchange plans. The insurer, however, covered only 795,000 people nationwide through the exchanges, so its withdrawal from the Missouri market is not expected to have a big impact.
“I went to VA hospital right here in St. Louis, John Cochran Hospital. At that hospital, over 1,000 patients were needlessly exposed to HIV.”
Between February 2009 and March 2010, more than 1,800 patients at the hospital came into contact with dental instruments that had not been adequately sterilized. More than 90 percent consented to testing. Two new cases of Hepatitis B and two new cases of Hepatitis C were identified in patients who either had not been tested or had previously tested negative.
“What we have here, what's so sad, is that we have outstanding results in the private sector. Look at what's happening with Mercy Hospital right here in the state of Missouri. We are one of the world leaders in telemedicine and in virtual care, making sure we can provide excellent, world-class care to our rural patients. Mercy has achieved outstanding results.”
It’s true that Mercy Hospital is achieving noteworthy results with telemedicine. (KCUR’s Alex Smith wrote about its new Virtual Care Center, which opened in St. Louis last fall.)
But while Mercy is in the private sector, it accepts Medicaid patients. Mercy officials have advocated for years that Missouri expand Medicaid. Vice President of Government Relations Mike Peters told the Joplin Globe in 2015 that non-expansion was “creating a hardship” for the hospital system. Mercy laid off 125 workers in St. Louis two years ago and another 350 system-wide last summer. It also shuttered its hospital in Independence, Kansas, another state that hasn’t expanded Medicaid.
Reached Thursday, Peters said Mercy is still advocating for Medicaid expansion in Missouri and the other states where it operates hospitals.
“Here's what the facts are: In 2000, Mel Carnahan's last year as governor, Medicaid consumed one out of five dollars of the state general revenue budget. Today, without expansion, Medicaid consumes one out of three dollars of your state general revenue budget.”
Overall spending on Medicaid has grown substantially in Missouri since 2000. The Pew Charitable Trusts says Medicaid spending in Missouri went from $5.2 billion to nearly $9 billion between 2000 and 2012.
Kinder, however, is only sort of right about one in three Missouri dollars going to Medicaid. Yes, Medicaid represented one-third of the state’s total expenditures in fiscal 2015, according to the National Association of State Budget Officers. But only about $1.7 billion of that came from the general fund. Another $2.4 billion came from provider taxes, fees and assessments, and $4.5 billion came from the federal government.
“It is growing at a rate faster than the growth in education funding, and the reason our superintendents and classroom teachers across the state have a complaint about funding not being what they would like it to be is because the explosive growth in Medicaid is crowding out K-12 education funding and higher education funding, which is sending tuition higher.”
It’s inaccurate to say Medicaid spending is growing at a faster rate than spending on K-12 education in Missouri. According to the National Association of State Budget Officers, both of these budget categories grew slightly and at the same (anemic) rate as each other. Between 2010 and 2014, K-12 spending grew by 1.5 percent as a portion of overall state spending, while Medicaid spending grew by 1.4 percent.
It’s more accurate to say Medicaid funding is crowding out education funding. But there’s a big caveat that Kinder left out. True, overall spending on Medicaid in Missouri has grown substantially since 2000 – as has the population (see above). And over the same period, the Missouri Budget Project, a nonprofit, public analysis organization, reports the percentage of per-pupil spending in Missouri that is covered by state funding has dropped from 48 to 41 percent.
But Missouri has been underfunding its K-12 schools to the tune of $400 million to $500 million every year. At the same time, the GOP-led legislature will forgo nearly $18 billion in federal funds by 2022 if it continues to reject Medicaid expansion, according to the Urban Institute. Some, including Gov. Jay Nixon, have argued these federal funds would free up revenue in the state budget for other things … such as education.
“Medicaid is a bargain the state's taxpayers can't afford. The states that have embarked on that road such as Illinois and others are looking at serious fiscal trouble. Anybody who tells you can expand Medicaid and expand education funding without a big tax increase has total contempt for his listener and believes he can pull the wool over your eyes.”
Under the Affordable Care Act’s Medicaid expansion provision, the federal government picks up 100 percent of the cost of expansion through 2016 and then ratchets down to 90 percent in 2020, staying at that level afterward. Experts say Missouri will actually save money by expanding Medicaid because it currently receives no federal matching funds for populations like prisoners in the custody of the Department of Corrections and some blind Missourians. Those populations are covered by state money instead. If Medicaid were expanded, most of that coverage would be picked up by the federal government.
Moreover, Missouri hospitals pay a provider tax that would cover a portion of the state match for expanded coverage. As a result, the state’s general revenue portion of the cost of expansion will be just 6.7 percent of the total cost, according to www.mobudget.org.
The Saint Louis University School of Law’s Center for Health Law Studies concluded that it would cost Missouri more not to expand Medicaid.
“I tell you the issue here – and all these facts are true here in terms of the expansion here – some studies have shown it would cost up to $3 billion over the next decade.”
A message we left with Brunner's campaign asking for help finding this study and others he cited wasn't returned. According to the Urban Institute, Medicaid expansion would cost Missouri $1.6 billion over 10 years. But that would be more than offset by the influx of federal matching dollars. A macroeconomic model commissioned by Families USA, a nonpartisan consumer health advocacy organization, found that Missouri would receive an additional $1.6 billion in federal Medicaid funds in 2016 alone to pay for health care. It estimated that $1.3 billion would be spent on health care in Missouri and the rest on providers in other states that treat Missourians enrolled in Medicaid. The model predicts that the $1.3 billion would have a significant multiplier effect on jobs and economic activity.
“This whole issue of advanced practical registered nurses and nurse practitioners is amazing. We're 50th in regulation in Missouri. Fiftieth place. And what does that mean? They're not allowed to practice up to their experience level. Thirteen other states have this freedom for them to practice.”
A 2007 article in the American Journal for Nurse Practitioners rated Missouri 50th (out of 51 jurisdictions) for access to nurse practitioner care. The Missouri Nurses Association cited that study in a 2014 white paper outlining its legislative goals, and CEO Jill Kliethermes says MONA has tried for the last five legislative sessions to get lawmakers to lift some of the rules and regulations governing advanced practice nursing without much luck.
MONA, however, supports Medicaid expansion, which could create an estimated 3,000 new nursing jobs in Missouri. Not expanding Medicaid, by contrast, could eliminate 5,000 hospital jobs.
“A Duke University study says this will save $390,000 a day, $100 billion a year. This is just one area. The portability for physicians in terms of their licensing is important.”
We couldn’t find a Duke University study citing Brunner’s $390,000 figure. But Duke has been doing research in this area. In North Carolina, it estimated regulatory reform for advanced practice nurses would generate at least $477 million in additional revenue. And in Pennsylvania, full practice authority for registered nurses could generate $6.4 billion over 10 years, according to another Duke study. A nice economic gain, to be sure, but nowhere near the $100 billion Brunner claimed.
Dan Margolies, editor of the Heartland Health Monitor team, is based at KCUR. You can reach him on Twitter @DanMargolies. Elle Moxley is a reporter for KCUR. You can reach her on Twitter @ellemoxley. KCUR’s Kyle Palmer also contributed to this report.