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Can Missouri afford 700,000 people without health care?

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Photo by Robert Joiner | Beacon staff
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This article first appeared in the St. Louis Beacon: August 22, 2008 On some summer evenings, after the sun and heat disappear and the weather turns cool and pleasant, Brenda Benedict sits on her front porch on Bellevue Avenue in Maplewood, does needlepoint and recites a prayer that nothing else will go wrong in her world.

A social worker for more than 30 years, she has now been pushed into the poorhouse by health problems and by cuts in Missouri's old Medicaid program. Politicians tend to talk about the program and the cuts in abstract terms, the millions of dollars spent or saved and the tens of thousands of people served or removed from the rolls. But Benedict puts a face that's at once sad and hopeful on these numbers, a face and an experience that show what was supposed to happen and what has actually happened since Gov. Matt Blunt pulled the health-care rug from underneath thousands of Missourians.

As U.S. Rep. Kenny Hulshof and Missouri Attorney General Jay Nixon hit the campaign trail, health care is certain to be among the top issues they will debate. For his part, Nixon has all but made it THE top issue with a bold proposal to spend millions of dollars, partly from federal money, to restore recipients and benefits that Blunt removed from the program. 

In 2005, Blunt cut out health assistance to 100,000 Missourians and reduced benefits to about 300,000. Nixon says that an estimated 750,000 Missourians, including 125,000 children, now lack health insurance. The Missouri Department of Social Services says the numbers are closer to 703,000, including 117,000 children. The goal, state officials said, was to limit the program to the truly needy.

Hulshof, the GOP gubernatorial nominee, has a major announcement coming on Aug. 27 on what his campaign calls  a "sweeping" proposal on health care and spending. 

Officials argue that no changes are needed and that the governor has fixed the problem. That line of reasoning comes from many in the Legislature and in state agencies. They include Jandra D. Carter, assistant to Deborah E. Scott, director of the Department of Social Services.

"The program was facing bankruptcy, and the governor was facing a difficult decision," says Carter. "He saved the system with changes that have made it better. His program focuses on wellness, prevention and coordinated care."

Can Missouri Afford Nixon's Plan?

Though Carter and others argue that Missouri can't afford Nixon's proposal, the attorney general shoots back that he's basing his figures partly on estimates from Carter's own department. Based on those numbers, Nixon estimates that restoring services to all those affected by Blunt's cuts would cost Missouri about $265 million a year in general revenue. He adds that Missouri could then draw down $431 million in federal matching funds that otherwise would be used by other states.

State social services officials do not dispute Nixon's numbers. "The numbers you have are correct," Carter says, "but what you have to understand is that there are competing demands on the revenues each year. Those revenues can only support so many of those demands, and there are other departments to consider. Once state dollars are committed, they have to be sustained from year to year and health care costs are going up every year."

This line of reasoning is echoed by GOP lawmakers who previously found a miscalculation in Nixon's numbers; they suggest that Nixon's plan would work for the short term at best. Some, like House Budget Chairman Allen Icet, R-Wildwood, suggest that Nixon's proposal couldn't be sustained without a tax increase. Even so, Nixon's spokesperson, Oren Shur, says Nixon intends to fix the system without raising taxes. Shur adds that the goal is to focus on the right spending priorities. The focus, he says, will be on needs, such as millions for health care, rather than millions on the kind of Blunt-backed tax credits that he says have benefitted wealthy developers.

The Cost Of Medicaid 

In any case, Medicaid has taken a big chunk of public dollars. It has grown sharply in nearly a decade, from a program that cost $2.6 billion and served more than 585,000 people in fiscal 1998  to one costing $6.1 billion and helping over 992,000 Missourians by the 2005 fiscal year. The numbers didn't rise on Blunt's watch. They went up over time because Missouri decided to cover more children and adults beyond the minimal federal requirements and because the poor economic situation made more people eligible for the program. At the governor's urging, GOP lawmakers passed SB 539, which is putting the brakes on both the cost and the number served. Spending has dropped to about $6 billion and the number served to about 826,000.

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A New Kind of Medicaid

Because of SB 539, Medicaid came to an end in June 30 of this year, replaced with a program called Missouri HealthNet. It's probably no coincidence that state health officials were in Nixon's hometown of Hillsboro on Wednesday talking up Blunt's MO HealthNet. There, Dr. Ian McCaslin, HealthNet's division director, told a town hall meeting that the program is "poised to help hundreds of thousands of Missourians maintain and improve their health status" through prevention, wellness and other programs.

But critics point out that, while this program might be useful for some health consumers, it doesn't address the problems of those whose health already is deteriorating.

Real People, Real Problems

One such person is Elizabeth Coleman, 54. When she was 10, the turning point in her life occurred, near Jefferson Avenue and Hickory Street in south St. Louis. She, a brother and her mother were in the street when men not far away began to argue. One pulled out a gun and fired over the head of her family, but the bullet hit a wall, ricocheted and struck her right hip. Because of that injury, her right leg is shorter than her left leg.

For 21 years of her adult life, Coleman worked in various jobs, including that of housekeeper, at Barnes Hospital. She eventually was let go because she couldn't walk. In time, due to lost income and the lack of a strong safety net, she lost her home, lived in the streets, eventually found a bed in a nursing home and later moved in with a daughter. At one time, she was able to make ends meet a lot easier: Thanks to Medicaid, her transportation to and from her doctors' offices, medicine and some other expenses were covered. She says she now struggles because she has to pay more out of pocket for having her medicine delivered, for transportation to doctors and for seeing her neurologist, orthopedist and other specialists.

Here's what really irks her. She's is well enough to live independently -- but with that independence comes a new requirement that she must cover more of her living and health-care expenses. If she moved into a nursing home, where she once lived, the state would cover more of her bills.

"If I get ill enough again I'd go back to the nursing home," she says. "But if I'm able to stay out and enjoy life a little bit, why shouldn't I? I enjoy looking at the trees, feeling the wind blow instead of being in a nursing home where there's lot of sickness, seeing people who'll never leave the place. That isn't a good place for me to be."

Some people will say Coleman is making her choice, but it's clear that the well-being of some individuals has been hurt by Blunt policies.

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Benedict's Lament

Benedict, the woman who lives in Maplewood, is one such person. She used to be a social work administrator who helped clients of Goodwill Industries navigate their way to independence. She finds it ironic that the door has been shut on a program that used to help her maintain her own independence after she became a victim of cancer, type 2 diabetes, and heart and back problems.

When sickness made it difficult for her to work, Benedict, 59, turned to Missouri's Medical Assistance for Workers with Disabilities or MAWD to help tide her over. It provided health insurance for Benedict and thousands of other Missourians whose disabilities made it difficult to work. MAWD is one of the programs that Blunt eliminated. Benedict now gets by on $1,080 in Social Security and a $416 a month part-time job in a resale shop. She has to cover her expenses -- rent, food, medicine and some health care costs -- from that income. Because of out-of-pocket costs, she says she rarely sees a specialist even though she says she needs to see one now for her back.

"MAWD allowed me to be independent, afford my medicine and gave me full health-care coverage," she says. "I'm making it, but that's because I'm resourceful, know how to live on a shoestring and just go without some medical care."

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Challenges for Health Clinics

Janet Voss, chief financial officer for Grace Hill Health Centers, has seen the problems first-hand. So many needy people walk through door with no means to cover even minimal cost that Grace Hill asks indigent patients to pay. The cost is $8 for a medical visit, $10 for dental care and $10 for a prescription for anyone with income of less than $10,400 a year ($21,200 for families of four). Grace Hill gets its funding from federal sources, but Voss says the funding isn't keeping up with the demand for services.

Middle-class Missourians may think that's not much, Voss says. "But we have chronically ill people who might need 8 prescriptions," she says. "That's $80, at $10 each, and that's a lot of money to them."

She's not passing judgment on the health-care cuts but explaining that many Missourians have a hard time covering their health expenses.

"It's just as important for people to understand that the problem extends to individuals who are hurting due to the downturn in the economy, people without jobs or without health insurance because they have lost their jobs. They, too, seek services from us."

A Doctor's Perspective

Budget cuts hurt the delivery end of the system, too, says Dr. Ingrid Taylor, who practices family medicine in north St. Louis County. She says some patients end up not seeing specialists because of the cost.

"There just aren't enough specialists available anymore because of the low reimbursement issue," Taylor says. "It's so low that some physicians just can't afford to see patients because they can't keep up with their overhead costs."

The debate in the governor's race won't be whether Blunt's remake of Medicaid will be changed but how much the next governor will be allowed to or willing to change. Hulshof apparently will now put forth a major proposal instead of saying, as he has previously, that the only thing Blunt's programs need is a little "tweaking."

Nixon, meanwhile, will face a different challenge if he is elected. His argument that Missouri can restore the cuts and expand services by taking advantage of federal money as well as money the state already is spending has broad appeal. But what if he's elected and the Legislature is still dominated by a GOP majority in the House and Senate? How much success would he have in convincing these GOP lawmakers to undo the changes to Medicaid that they supported wholeheartedly under Blunt?

It is a debate and an election that Benedict for one will watch closely. In the meantime, "I sit on my porch and watch the trees and my flowers and needlepoint and watch the rabbits and listen to the doves," she says. "When you're in a chaotic situation the way I am, it's important to create peace and harmony. But I know I'd be a lot better off if I had better health care."

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.

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