As one might expect, Republicans and Democrats vying for the Missouri House of Representatives District 60 seat differ widely on whether the state should have expanded Medicaid.
The Republicans - Jane Beetem, Pat Rowe Kerr and Dave Griffith - argue the cost to Missouri would be too high, would stifle growth and would keep wages low.
Democrats Kevin Nelson and Sara Michael counter that it would protect the state's most vulnerable citizens, prevent rural hospitals from losing money and create jobs.
Medicaid is a joint federal-state program intended to provide health coverage or nursing home coverage to certain categories of low-asset people, including children, pregnant women, parents of eligible children, people with disabilities and elderly needing nursing home care.
Candidates must listen to the discussions between rural and urban hospitals to help develop an alternative to expansion, Kerr said.
"Obamacare has failed," she said. "States that expanded Medicaid have skyrocketing expenses."
Kerr pointed out the Jan. 31, 2017 congressional testimony of Josh Archambault, a fellow at the Foundation for Government Accountability, a conservative think tank based in Florida. Archambault was critical of states that had expanded Medicaid, saying many had improper payments even years before the expansion went into effect in 2013.
Democrats argued expansion favors rural Missourians.
In early July, a New York Times article examined data from 2011-15 that looked at how Medicaid funding affected community health centers, which provide services for medically under-served inner city and rural areas. The centers combine local resources and federal funds to establish neighborhood clinics. In urban areas, there was no significant change in quality of care. But rural areas saw increases in the number of patients who received preventive treatments.
Beetem said expanding Medicaid would not change people's behaviors, such as smoking, drinking, using drugs illegally or committing crimes. She said a better approach is to help people get jobs with health insurance and explore ways to expand treatment in rural areas and to provide drug treatment programs.
"Access to affordable care is needed by all citizens, to control disease and maintain health," Beetem said.
Not all Missourians understand what Medicaid is and how it is used, Griffith said. He worries there is a great number of people using Medicaid who are not eligible for the program.
"We can find a better way to provide health care for all Missourians," Griffith said. "We've got to stop people from going to the emergency room so much. That drives up costs."
The Samaritan Center and community health centers are "really good alternatives," he said.
The failure on the part of the Missouri General Assembly to expand Medicaid in 2014 caused the state to lose about $17.8 billion in federal funding by 2022, Michael said. Meanwhile, Missourians' federal taxes are being used in other states.
Expanding Medicaid is still on the table, Nelson said. Even now, if Missouri were to expand Medicaid, it could remove a burden that many vulnerable people are facing.
"More federal dollars are going to flow in than what (Medicaid expansion) is going to cost the state," Nelson said. "It's time to get it done. We're hurting Missouri citizens by not passing this legislation - workers, citizens, health care providers."
It's not just about state dollars in and state dollars out, Michael said.
"Hospitals won't be losing money on people they treat who fall in the health care gap," she said. "Jobs will be created in health care. It will provide better health care and viability for our citizens."
In late June, Virginia became the 33rd state to commit to expansion. Still, Missouri's conservative Legislature is far from considering it. Senate Bill 713, which would have expanded Medicaid eligibility to include adults with income up to 138 percent of the poverty level, never got out of committee in the 2018 legislative session.
Expanding Medicaid would be irresponsible, Griffith said. Much more research is needed, he added.
Missouri already has a generous social safety net that takes up a massive portion of the state's budget, Kerr said. Expanding Medicaid would just trap people in poverty.
A better idea, she said, is to support work requirements and expanded job training to get people back to work and out of a "poverty cycle."
"The benefits of expansion are tremendous and very much needed," Nelson said. "And to reject it based on political ideology is a terrible disservice."