Despite the efforts of healthcare advocates, hospitals and notable former legislators, the Missouri legislature did not pass Medicaid expansion this year, or even bring it to the debate floor. That means an estimated 147,000 Missourians will have another year without health coverage, and the community health clinics that care for the uninsured will continue trying to bridge the gap.
“I don’t know what it will take, I don’t know what more information [lawmakers] need to motivate them to change,” said Dr. Johnetta Craig, Chief Medical Officer at Family Care Health Centers in St. Louis.
Craig said that if the past two years are any indication, patients will defer care when they can’t afford it, leading to emergencies and more expensive health care down the road.
“When you talk about hypertension, diabetes, dyslipidemia, those diseases unmanaged are precursors to worse things happening,” Craig said. “We’re setting ourselves up for more costly health care interventions.”
About 31 percent of Family Care’s 20,000 patients are uninsured, and most pay for appointments out-of-pocket on a sliding fee scale. About 1,700 are covered by a temporary federal program that pays for primary care visits.
Republican lawmakers cited issues with Missouri’s existing Medicaid program, MO HealthNet, as evidence that it should not be expanded to cover people who earn up to 138 percent of the federal poverty level. (The current limit to qualify for Medicaid is 18 percent of the poverty level for adults with children, or $2,118 a year. Children and people with disabilities qualify at higher income levels.)
In the meantime, community health clinics in St. Louis have played a major role in taking care of the people who fall into Missouri’s “coverage gap.” A temporary program called Gateway to Better Health uses federal funds to offer primary care, and doctors say they’ve learned how to do more with less. But in the health care safety net, funding is a mash-up of federal grants, insurance reimbursements and patient co-pays, which can be tricky to navigate.
“If something happens in D.C. that would restrict our funding, that would be a real challenge to us,” said Dennis Kruse, Family Care’s Chief Financial Officer. Congress passed HR 2 to continue payments to community health centers like Family Care last month, but the measure still has to go through the appropriations process.
“That’s $2.3 million [of federal funding] that’s out there as a potential hit,” Kruse said. Family Care takes about 20,000 patients annually, with total operating costs of about $15.6 million, according to federal data.
In addition to that chunk of federal funding, the Gateway to Better Health program reimburses health clinics like an insurer would for St. Louis city residents who make less than 100 percent of the federal poverty level. Patients in the Gateway program have access to primary care appointments, generic medications and some specialty services. But the program must re-apply for its federal grant annually. Officials say they haven’t heard anything to suggest they would lose funding this year, but it’s always a possibility.
“Every year we’re worried about it,” said Kruse, who estimates that Family Care’s involvement in Gateway brings in about $850,000 a year.
Medicaid expansion, he said, would offer a more stable revenue stream for all community clinics in St. Louis.
For Family Care board president Wilma Schmitz, access to health insurance is personal. Years ago, her sister lost her job and her health insurance after being diagnosed with a brain tumor. Friends and neighbors have told her they lost their Medicaid coverage after getting jobs, which pushes them over the income limit for Medicaid, but they still aren't making enough to buy health insurance.
Schmitz herself lived without health insurance for four years, and the feeling she most remembers is “terror:”
“I love riding bicycles, for example. If I was to fall, what was I going to do?” Schmitz said. “I’ve seen and heard horror stories where people lose everything.”