Missouri legislators' refusal to expand Medicaid will cost lives and money, according to several medical organizations. However, elected officials still are uncertain about the future for a Medicaid expansion or reform in the state.
At the moment there is no legislation filed to expand the Medicaid program or opt into the Affordable Care Act's (ACA) expansion guidelines. Twenty-nine states have opted in, not including Wyoming and Utah. Wyoming Gov. Matt Mead, a Republican, has endorsed expansion, and Utah lawmakers are working with the federal government on their own expansion with reforms.
Several Missouri representatives from both parties have shown a desire to either reform or expand Medicaid to provide health insurance access to low-income individuals and their families. But lawmakers on both sides are uncertain the issue will be brought up again in the House, said Reps. Jay Barnes, R-Jefferson City, and Jeanne Kirkton, D-Webster Groves.
Past attempts to expand Medicaid eligibility in accordance with ACA guidelines has failed in the state's House and Senate due to a lack of Republican votes.
"The bill last year would have expanded managed care statewide to bring down cost," Barnes said about his previously proposed legislation for Medicaid reform. "Doing it the wrong way would be a terrible idea, but doing it the right way could give Missouri the most market-based Medicaid system in the history of the program. ... I wanted to increase eligibility to 100 percent of the federal poverty line, and I also would have reduced eligibility in a number of categories as well."
Barnes has voted against the ACA expansion for Medicaid six separate times and believes the normal expansion is throwing money at an idea with a bad foundation. For the current session, Barnes has filed three "small-ball" Medicaid reform bills, none of which expand Medicaid eligibility.
At the moment, Medicaid expansion through the federal plan provides coverage for those who earn below 138 percent of the federal poverty line.
States that opted out of expansion have created a coverage gap where thousands of uninsured people make too much money to qualify for Medicaid, but still not enough to afford private insurance, Kirkton said.
"I think that (House Speaker John) Diehl has made it clear that it is dead on arrival in the House, but that is not going to stop several of us from filing Medicaid expansion bills," she explained. "The likelihood of them seeing the light of day is pretty slim. ... Any movement we see is probably going to be from Sen. (Ryan) Silvey, but even if he does send something over here to the House, Diehl does not have to even bring it up. I am not hopeful."
As of Wednesday, more than 197,000 Missourians have signed up for insurance through the federal marketplace and nearly 89 percent qualify for financial assistance, said Sylvia M. Burwell, secretary of the U.S. Department of Health and Human Services.
This may have little effect on the roughly 800,000 uninsured Missourians, because that 197,000 includes those who have just switched plans, said Nancy Kelley, program director for the Cover Missouri Coalition.
Expanding Medicaid would cover more than 238,000 of those people, according to a study by Healthaffairs.org, which used data from the Census Bureau and Congressional Budget Office to determine eligibility.
That same study said expanding Medicaid last year would have allowed more than 12,000 people with diabetes access to medication; 4,000 women access to cancer-detecting mammograms and 14,000 other women access to pap smears, which also detect cancers, and would have decreased the number of Missourians with "catastrophic medical expenditures" by more than 7,000.
The study also estimated between 218 and 700 deaths could have been prevented if the expansion had occurred.
At a recent news conference, Diehl said Medicaid expansion is unlikely because he does not see an "appetite" for it, and he doubts anyone has died because Medicaid has not expanded eligibility.
Expansion supporters say it is likely no one will directly die from a failure to create legislation that expands Medicaid eligibility, but it is more likely people will die from a lack of access to health care.
House Minority Leader Jacob Hummel, D-St. Louis, said House Democrats will continue to push for Medicaid expansion, despite their small numbers.
Three arguments from House Republicans for not expanding the program are that the state cannot afford to expand, the federal government is funding the program with money it does not have, and the state would have to foot the bill if the federal government stops paying for it.
In terms of money, the Missouri Hospital Association (MHA) keeps track of how much federal funding they believe the state has lost since January 2014 for not expanding Medicaid. Their counter, on Missourihealthmatters.org, is constantly increasing and was at more than $2 billion on Thursday afternoon.
"We are all federal taxpayers and we are all paying for that coverage to be elsewhere," said Dave Dillon of the MHA. "We are not getting a refund of federal taxes because we failed to expand. ... The ACA is not a giant new spending program. In fact, the Congressional Budget Office has scored it for cost and found it to be revenue neutral."
Through the ACA, the federal government has agreed to fund the expansion for the first three years at 100 percent, then fund 90 percent of the cost indefinitely, Dillon said.
"The ACA funding was predicated on raising some new money and cutting existing payments - it is not funny money," Dillon said. "If you are not in this game as a state you are losing, because the truth of the matter is that each taxpayer that is not participating is paying for it twice.
"Not only are you paying federal tax dollars, but if you have insurance now the likelihood of paying more for people who are not covered by Medicaid is more. We call it the hidden health care tax."
This hidden tax is commonly referred to as cost-shifting by MHA studies. It occurs when health care providers charge more to privately insured patients to cover the losses from treating uninsured or under-insured patients who default on payments.
Missouri hospitals spent $10.5 billion for uncompensated care for the uninsured in the past decade, according to an MHA study. It also stated Medicaid expansion or reform could offset $11.1 billion in uncompensated care costs and reduce the "hidden health care tax" burden for the privately insured and employers.