At any given time, a half dozen people sit in the waiting room at Affinia Healthcare in south St. Louis. Two parents coo over a new baby, while a group of older patients chat along the back wall.
53-year-old Keith Carter sits alone. An embroidered polo shirt and badge show he’s just come from work.
“I seem fit. Inside, it’s just breaking down like sawdust. I just keep it in motion,” he said, as he waited to pick up a prescription to manage his diabetes.
Three years after Missouri’s legislature first shut down the option to expand Medicaid through the Affordable Care Act, an estimated 173,000 adults who could have been covered by the law remain uninsured. Many, including Carter, turn to publicly funded health clinics like Affinia for care, where they can see a doctor for a small fee. It’s in these waiting rooms where the effects of Missouri’s “coverage gap” come to the forefront.
Stuck in the middle
People in the gap make too much money to qualify for MO HealthNet, Missouri’s existing Medicaid program, but too little to receive a federal subsidy to buy coverage on Healthcare.gov.
Carter works as an independent contractor for a courier service in St. Louis, so he cannot get health insurance through his work. Carter lives in St. Louis, so he can use the temporary Gateway to Better Health program, which covers his preventive care. But it’s not “health insurance” per se—if he’s ever admitted into a hospital, he’ll probably have to pay out of pocket. He said that he worries about having an emergency every day.
“At any given time, my sugar could drop,” Carter said. “You never know when you’re going to get sick as you get older… just like this diabetes happened to me, I never knew I had the symptoms or the traits of it.”
About 109,000 Missourians fall between these income guidelines, according to an analysis by the Kaiser Family Foundation. Due to a quirk in the Affordable Care Act, another 60,000 or so who would qualify for Medicaid under an expansion bill can already qualify for subsidies because they make more than the federal poverty level. Income limits for MO HealthNet vary, but in general, a Missouri family of four making anywhere between $4,374 and $24,300 a year could find themselves in this situation.
Mona Bryant, a patient who has since been able to sign up for health insurance on the exchange, found herself in the same situation last year.
“I was supposed to go on insulin, but I couldn’t afford the insulin, so I just had to take the sugar pills and hope my sugar [would] pan out ok,” Bryant said. “You just got to be careful and mindful of your condition."
Little support for expansion in Jefferson City
Though bills to accept federal money to expand Medicaid did not make it far in the Missouri legislature this year, the Republican-controlled House allowed supporters to have a brief floor debate in March.
House budget chair Tom Flanigan, a Republican, stood firm against adding people to the state’s Medicaid program, which already covers about 980,000 adults and children, and costs $8.2 billion a year.
“It’s a big lug on our budget, it prevents us from doing a lot of good work in this body. And I too will oppose any increase in Medicaid,” Flanigan said.
The state of Missouri oversees its own Medicaid program, but the funding comes from both federal and state sources. Expanding Medicaid this year would have drawn $1.8 billion in federal dollars to expand eligibility for adults to 133 percent of the federal poverty level. The limit currently sits at 18 percent for parents, and does not cover able-bodied, childless adults at all.
Democrats argued that legislators had a moral obligation to expand the program, but were outvoted by Republicans, 37 to 109.
Missouri is one of 19 states that have not expanded Medicaid or issued an alternate plan to accept the funds to do so. Three of its neighbors—Iowa, Illinois and Arkansas—have expanded their programs.
Providers feel a stretch
In the meantime, community health clinics continue to do what they can to meet the needs of Missouri's uninsured residents. Some still lack coverage because they can’t afford it, don’t know they qualify or are waiting on applications to process. Some have no other option because they are undocumented.
People in the gap make up a large portion of the patients seen by Dr. Melissa Tepe, Affinia’s medical director. About half of Affinia’s patients are uninsured—most of the rest are covered by Medicaid.
“I’ll see a lot of waitresses, cab drivers, folks who do seasonal work,” Tepe said, on a break between appointments. “I think a lot of patients work their bodies to the very edge.”
Tepe said that when her patients don’t have insurance, they delay care or skip medications because they can’t afford to pay out-of-pocket. That makes their health go from bad to worse.
“What happens to their families when these folks aren’t able to live to their potential, right? Are they going to come out of the workforce because their diabetes is too bad?” Tepe said.
“It’s very easy to look at a band aid and say nothing’s profusely bleeding, but that ignores the big problems behind it,” said Angela Schiefelbein, a nurse practitioner at another Affinia location.
Emotion strains her voice when she talks about her patients. One, a 50-year-old woman has never smoked but lives with a severe case of asthma and is now oxygen dependent. Schiefelbein said she knows that patient cuts back on food and can’t always afford her medical supplies because she has to pay her rent. Another patient started having seizures, and might lose her job because she’s missed too many days at work—but can’t afford to see a neurologist or take medication.
“There’s a very good chance she’s going to end up in a shelter—she’s never been in one before,” Shiefelbein said. “This is the face of people who are in shelters now. One health crisis away from being homeless.”
Follow Durrie Bouscaren on Twitter: @durrieB