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With Medicaid expansion out of reach, backers work to salvage another key health program

This article first appeared in the St. Louis Beacon, May 28, 2013: St. Louis and St. Louis County started a promising pilot program last year to extend medical care to more of their working poor. Called Gateway to Better Health, the program offered the uninsured the chance to trade costly emergency room health care for a better-coordinated system that links people to medical providers at health centers.

By all accounts, the program has worked well, extending outpatient care to roughly 25,000 more needy residents who were ineligible for assistance through the state's restrictive Medicaid program, called Mo HealthNet. 

Gateway was part of a larger effort to reach more of Missouri’s medically needy in anticipation of plans to expand Missouri Medicaid under the Affordable Care Act.

But Gateway enrollees might be out of luck because state lawmakers refused to expand Medicaid, citing the federal deficit and arguing there was no guarantee that the federal government would keep its bargain to cover the cost of expansion for the first three years, starting in 2014, then cover between 90 percent to 95 percent of the cost after that.

The expanded Medicaid program, which states can accept or reject, extends health benefits to needy individuals with incomes of up to 138 percent of the federal poverty level. That comes to slightly more than $15,000 for an individual and nearly $24,000 for a family of three.

The Regional Health Commission took the lead in setting up Gateway to Better Health. Robert Fruend, CEO of the commission, says the area now faces a big challenge in persuading the federal government to grant a waiver to keep the program.

Otherwise, he says, the 25,000 enrollees could be without health insurance on Jan. 1, when Gateway is to end and Medicaid expansion begins.

He says this issue comes just as the region will face major challenges in serving uninsured patients left out of Medicaid expansion.

“Hospitals are going to start seeing reductions in their disproportionate share payments” for treating uninsured patients, he says. The assumption was that some of the subsidies no longer would be necessary because Medicaid expansion would allow needy patients to get care in clinics rather than emergency rooms.

The end of the Gateway program, Fruend says, will also result in the loss of 25 percent of local health center funding. “It’s going to be hard for community health centers to maintain services with $30 million less,” he says.

The health center picture statewide is just as bleak, says Joe Pierle, head of the Missouri Primary Care Association. Without Medicaid expansion, he says, the uninsured needy would have few good options for medical care.

“Sure they can come to community health centers," he said. "They can go to emergency rooms, rely on volunteer-based clinics. Or they can choose not to seek care at all."

Pierle says health centers treat 450,000 patients statewide, including 150,000 who are low income and uninsured, but they still aren’t reaching all who need care. He says free clinics typically are opened one night a week, “so if you are sick the remaining six nights, you are in a tough position.” 

One exception is the highly regarded free clinic in St. Louis, Community Health in Partnership Services or CHIPS, which is open daily.

At least 260,000 Missouri residents were projected to get health benefits through Medicaid expansion. Aside from setting up the Gateway to Better Health, the St. Louis Regional Health Commission and the Integrated Health Network have worked with clinics in enrolling an additional 20,000 residents, more than half of them children, in the existing Medicaid program. They would continue to receive health benefits next year.

In addition to Medicaid expansion, as many as 525,000 residents are expected to receive tax credits to help them buy affordable health insurance through an insurance exchange program on the Internet. This program is open to households with incomes between 100 percent and 400 percent of the federal poverty level, meaning a family of four with an income up to $94,000 would be eligible.

The failure to support Medicaid means Missouri will lose millions of dollars in health benefits for its residents as well as an opportunity to boost the state’s economy through new jobs and expanded medical services.

Proponents, like Pierle, say it’s essential to try again next year to convince lawmakers to reverse their opposition to expansion. Herb Kuhn, CEO of the Missouri Hospital Association, adds that he’s encouraged by the legislature’s plans to form interim study committees that try to come up with a plan “that meets both the needs of the state and its citizens.

Not all groups feel the legislative inaction was a bad thing. Bev Randles, chair of Missouri Club for Growth in Kansas City, says state lawmakers sent the right message in turning back Medicaid expansion. She argued that a poll commissioned by her group reinforced that feeling, with 70 percent of residents opposing expansion

Pierle says such poll results can be misleading. “It depends on the way the question is phrased,” he says. “If you take some of the individual components” of Medicaid expansion, “people support them. But when the program is characterized as Obamacare for political reasons, people  have a negative reaction.”

He added that expansion is supported by border states, such as Illinois and Arkansas, and perhaps Iowa as well.

“One of the most compelling things is that we are surrounded by states that are going to receive tax dollars that should go to Missouri," Pierle said. "I’d rather keep those tax dollars inside Missouri’s borders and improve our health care system.”

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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