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Missouri Legislature leaves health clinics still scrambling to help the uninsured

This article first appeared in the St. Louis Beacon, May 16, 2009 - One of Dwayne Butler’s proudest moments as CEO at People’s Health Centers in St. Louis came on the morning of March 9 when he joined Gov. Jay Nixon in announcing what they described as a win-win way to expand health insurance for Missouri’s needy and unemployed.

People’s, at 5701 Delmar Boulevard, was the governor’s first stop that morning, the beginning of a major publicity campaign across Missouri to persuade state lawmakers to support Nixon’s efforts to bring health care to nearly 35,000 needy parents at no increased cost to the public.

In the face of a serious economic downtown, Missouri’s uninsured population exceeded 750,000 and was growing. Nixon saw his proposal as a modest step toward trimming the numbers. He had worked out an agreement under which hospitals would pick up the $53 million tab to allow Missouri to draw down about twice that amount in federal matching Medicaid funds to provide coverage for the 35,000 working Missourians.

Marc Smith, the Missouri Hospital Association chief who also was at the meeting at People’s, called the plan  “an opportunity we can’t afford to miss.”

But many members of the Missouri Legislature decided the proposal, SB306, was an opportunity the state could pass by. They defeated the proposal as the this year’s legislative session came to an end at 6 p.m. Friday. The Missouri House also killed a more restrictive plan, HB156, a health savings account approach which Democrats held their noses and supported because it provided some relief to targeted 35,000 low income families.

Renewed National Debate

Friday’s outcome in Jefferson City, symptomatic of a national uninsured crisis worsened by layoffs and recession, is likely to give an added sense of urgency to the latest health reform debate just beginning on the national level and to a push to make health insurance accessible to every American.

Within two weeks, on June 1, some key players who have traditionally opposed major health reforms promise to deliver President Barack Obama a plan to remove about $2 trillion in fat from the current system. In theory that’s enough money to cover an estimated 46 million Americans who lack health insurance. Obama and Democrats are hoping the proposal from health industry players will give a boost to passage of a major health reform bill this year.

Meanwhile, Jefferson City’s rejection of the Nixon proposal means CEO’s like Butler and hospital emergency room officials as well are back where they started for now.

“I’m very disappointed that this health legislation was voted down,” Butler says. “This makes it difficult for us. We have to find creative ways to cover the cost of caring for all patients, the uninsured and the underinsured, that we see.”

Stress Inside Health Centers

Joe Pierle, CEO of the Missouri Primary Care Association, which represents health centers across the state, says the proposal offered a sensible way to expand care for the needy and ease some of the pressure on health center budgets at a time when patient loads at these centers have risen about 17 percent in the past two years.

“There certainly doesn’t seem to be a slow down of that increase,” he said. “The economy has been tanking and we have higher unemployment than we’ve had in a long time and can only assume that the uninsured rate overall is going up because people have lost jobs and lost their health insurance.”

This means health centers “will feel that pinch and most of them in the St. Louis area already see close to a 50 percent uninsured population or higher. It puts a significant strain on the organization.”

GOP lawmakers who opposed the Nixon plan insist that they are not heartless but are being fiscally responsible because there may not be money down the road to cover the expanded health care in later years and because people should be required to pay something for the care. Under SB306, a parent would have qualified for the health insurance if the family income earned up to 50 percent of the poverty level – or roughly $11,025 for a family of four. But since the legislation didn’t pass, such parents will continue to be eligible for health care only if the family income is less than 20 percent of the federal poverty level. For a family of four, that means income of about $4,410 a year.

Even $8 Is A Burden

Butler, Pierle and others know from experience, and from studies as well, that poor families have a difficult time making even a modest payment – $8, for example – for a visit to see a doctor. Federal guidelines require clinics to set a sliding fee, based on income, for service.

“You have folks who are unemployed or who are working multiple part-time jobs and have to pay the rent and other expenses. For these families, the sliding fee can be a challenge,” Pierle says.

“I’d say this is probably the worst I’ve seen in terms of the burden placed on health centers and hospital emergency rooms trying to keep up with the demands and the number of uninsured. If you have a patient fee of $8 but the cost of providing the care is around $100, you have to make up the differences somewhere.”

A week ago, as state lawmakers rushed to finish the budget by the May 8 deadline, SB306 looked dead. At that time, Pierle remained optimistic because House leaders promised to try again to act on SB306 during the final week of the legislative session.

At that time, Pierle said, “I’m still hopeful we can work out some kind of compromise.”

His optimism didn’t wane until around 6 p.m. on Friday.

“The saddest thing about it,” he says, “is you had a proposal on the table to take money already in the health care system (through hospitals donations) and use it more cost effectively to provide health coverage at no cost to the state.”

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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