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Hospital Association seeks to reshape Medicaid debate with 'A View of Two Missouris'

This article first appeared in the St. Louis Beacon, Sept. 19, 2013 - An uninsured parent of two children would have to bring home less than $9.59 a day to qualify for Medicaid in Missouri, the federal-state insurance program for the needy.

"This precludes almost all working adults from Medicaid eligibility in Missouri,” says a study, titled A View of Two Missouris, released Tuesday by the Missouri Hospital Association.

“Because of these strict eligibility standards, a large number of Missouri’s uninsured are low-income working adults in blue collar and service collar industries who cannot afford to purchase private health insurance.”

The study frames the health-care debate in global terms, noting that on matters of health and productivity, Missouri must not only compete with the state next door but with countries around the globe. In some instances, the report implies that Missouri is falling short of some poor nations.

Family SizeYearlyMonthlyWeeklyHourly
3$3,515$292.92$67.60$1.69
4$4,239$353.25$81.52$2.04
5$4,963$413.58$95.44$2.39

Weekly figures based on 52 weeks. Hourly figures based on 52 weeks at 40 hours a week.

The MHA is using such arguments as part of an ongoing public discussion over whether state lawmakers should expand Medicaid to cover the working poor with incomes below 100 percent of the poverty rate, the equivalent of $19,530 a year for a family of three. At the moment, Missouri caps Medicaid eligibility at 18 percent of poverty, which comes to $3,515 a year — or $9.59 a day — for such families.

This issue continues to be debated because of changes Congress made in the Medicaid law when it passed the Affordable Care Act, commonly known as Obamacare. The changes authorized states to expand Medicaid to cover adults under age 65 as long as their income was no higher than 138 percent of the federal poverty level — roughly $26,900 for a three-member family such as the one mentioned in the MHA report. The federal government offered to cover the full cost of expanding Medicaid through 2016, and it promised to cover no less than 90 percent of the cost in later years.

Missouri is among 27 states that have refused to expand its Medicaid program. The reasons include belief that the federal government won’t keep its end of the bargain and philosophical opposition to either Medicaid expansion or Obamacare or both. State lawmakers have promised to revisit the issue during the next legislative session, but it’s unclear whether a majority will agree to expand Missouri’s program.

The irony is that the poorest of Missouri’s poor are hurt the most if Missouri doesn’t expand Medicaid, which was set up to be a safety net for the very poor as well as a source of funding for nursing home care for the elderly.  While indigent families earning more than 18 percent and less than 100 percent of the poverty line won’t have access to Medicaid, those with incomes above 100 percent might be eligible for assistance under part of the ACA called the health insurance exchange system. It begins enrolling consumers on Oct. 1. Those people will be able to get federal subsidies for their insurance through a marketplace exchange at healthcare.gov. Subsidies will be available to some consumers earning up to 400 percent of poverty — roughly $78,100 for a family of three.

The MHA report argues for expansion in part by contrasting life expectancy and, by extension, productivity between residents in various ZIP codes and between Missouri and some countries.

The report points to the St. Louis Place neighborhood in the 63106 ZIP code, where it says life expectancy for a child born there is 69 years. Life expectancy rises sharply in places only a short distance from the center of the 63106 ZIP code:

• Eight miles to the southwest in the St. Louis Hills neighborhood, life expectancy is 13.2 years higher.

• Six miles west in St. Louis County, the increase is 9.4 years.

• Eighteen miles northwest in St. Charles County, residents enjoy an added life expectancy of 10.9 years.

Variations differ by Missouri counties, too.

The report says average life expectancy at birth ranges from 71 years in Pemiscot County to more than 80 years in St. Charles, Platte and Mercer counties — a difference of 9.3 years of 13 percent, the study says.

A town hall meeting organized by ACA opponents, and billed as an information session, packed the auditorium Tuesday night at Maryville University. Missouri House Speaker Tim Jones and others denounced the program. About 20 people attended a less-publicized event a few miles away organized by supporters of the program.  —

“Missouri counties with short life expectancy also have significantly higher rates of unemployment and much lower household income,” the study notes, mentioning 11 counties in the southeast quadrant of the state, as well as the city of St. Louis.

"Missourians living in those areas can expect to live two years less than residents of Vietnam and Venezuela and a year less than Hondurans and Lebanese.” It adds that if Missouri’s Pemiscot County were a country, it would enjoy the world’s 85th lowest life expectancy.

Missouri’s refusal to loosen eligibility for Medicaid not only affects the quality of life in parts of the state but also has implications for productivity, according to the report.

"Without the improvements in the overall health of Missouri’s population, the state will not realize the gains of lower cost, better-quality health care or increased worker productivity,” the MHA report says.

It notes that more than 800,000 Missourians were without health-care coverage in 2011. Nearly three out of four uninsured Missourians were in a working family, with more 54 percent of them having at least one full-time worker. Roughly 38 percent had incomes below the poverty level and 90 percent earned less than 400 percent of poverty, the upper income limit for getting insurance subsidies under the insurance exchange program.

The study also pointed to Oregon as an example of how health insurance makes a difference. Researchers found that access to health insurance in that state had a positive impact in mental health, quality of life, use of preventive health services and financial stability.

In Oregon, “clinical diagnoses for depression decreased by over 30 percent, and health-related quality of life improved by nearly 10 percent for the newly insured participants,” the MHA report said.

The MHA report says similar results could be realized in Missouri if the state expanded health insurance to reach those below 138 percent of poverty. The benefits would include fewer cases of depression, more access to primary care, more preventive health screening, fewer cases of catastrophic medical spending and bankruptcies.

"Productivity gains associated with expanded public health care coverage will result in pure returns for Missouri employers,” the study says, adding that the benefits are magnified during the first three years of expansion because the federal government picks up all of the cost.

Added health-care cost to a worker "is offset by higher lifetime earnings,” a more productive workforce, and fewer days lost to illness, the study concludes.

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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