More than 800,000 Missourians are uninsured Missourians, and the rate of uninsured has risen from 6.6 percent in 1999 to more than 13 percent today, Washington University health economist Timothy McBride told a state Senate committee Wednesday.
He attributed the increase to the state's deindustrialization and the loss of manufacturing jobs, as well as a broader trend away from employer-provided coverage.
"To improve the population's health and enhance the consumer experience, I think expansion of Medicaid is part of the two-pronged approach I think the committee should consider," McBride said.
He was one of a handful of witnesses from health care groups and other concerned organizations who testified in front of the Senate committee, sharing their experiences of providing health care across the state and urging the senators to reform and expand Missouri's Medicaid system.
The witnesses represented nonprofit health care providers, a St. Louis business group, the Consumers Council of Missouri, the Missouri Association for Social Welfare and the Boone County Sheriff's Department. They discussed the demand side of care and addressed the challenges that different populations present.
The committee was formed to explore Medicaid reforms and expansion and was developing a report and possibly draft legislation by mid-December.
McBride estimated about 260,000 new people would enroll if the Missouri General Assembly expanded Medicaid, with the biggest increases coming from rural areas in the southeast and southwest portions of the state.
"There is probably no health policy expert around who doesn't think we can improve on Medicaid programs, and certainly we can do that in this state, but I would also point out that we are already doing that," McBride said.
Ed Weisbart, vice president of the Consumers Council of Missouri, told the committee how strategies such as preventive care, electronic records and performance-oriented pay do not necessarily reduce costs as effectively as many people argue.
To expand care to those who need it, Weisbart said the state must create financial incentives for doctors to work in under-served areas by reimbursing physicians at 120 percent of Medicare rates.
He said these communities would then have a wealth of well-paying patients and not many doctors, so there would be incentive for doctors to work in areas with large under-insured populations.
"If you make this one change, you wouldn't get more doctors going into medicine, but you would get less doctors leaving Missouri to go to states that are doing that," Weisbart said. "Absent that, everything else is rearranging deck chairs on the Titanic."
Businesses also have a stake in Medicaid expansion because the costs of uncompensated care for treating uninsured people is passed on to other payers, such as employer-based plans. Louise Probst, executive director of the St. Louis Area Business Health Coalition, which represents more than 50 businesses, said her organization supports expanding Medicaid.
"Health care does not exist in a silo," she said. "We pay for health care in silos ... but what happens in one sector affects the other. So what happens in Medicaid is of importance to the business community and impacts business."
While focused preventative treatment may not save money on paper, Craig Henning, executive director of the Disability Resource Association, said he is convinced from his experience that it works to reduce costs and improve patient outcomes.
"I want a system of holistic case management that provides heavy preventative care and health care monitoring - also, more highly coordinated mental health services," Henning said.
He also pointed to the challenges that rural patients face in setting up appointments that they are able to get to.
"Rural people experience a great difference in access due to transportation and also a shortage of a physicians," Henning said. "If you can't coordinate with your doctor to set up an appointment, the easiest thing to do is to go to the ER and that costs multiple times more than seeing a doctor."
The hearing was the last for the Missouri Senate Interim Committee on Medicaid Transformation and Reform.
Committee Chairman Gary Romine, R-St. Francois, said they would get together in the next month and start revising a draft proposal.
"We will digest it, chew it up, tear it apart and rebuild it," Romine said. "The last thing I want is to go through all of this and not put something on the table."
Sen. Joe Keaveny, D-St. Louis, said the committee and eventually the Missouri General Assembly faces two major hurdles to overcome: what percentage of poverty would be covered by expansion and how much of the expansion would be managed care versus fee for service.
"I do think there will be some kind of expansion," Keaveny said. "By the time we get back in session, the Affordable Care Act will be fully implemented and that should take some of the politics out of the discussion."
Some of the panel's Republican senators, however, said they were still focused on how to reform the current system before they would consider expanding the pool that Medicaid covers.
The committee also heard testimony by three members of the Senate research staff, who presented information about payment reductions to hospitals across the state as a result of sequestration and Medicare cuts.
Marga Hoelscher said the reductions between 2013 and 2019 could total as much as $4 billion, similar to the estimates of how much money expanding Medicaid would bring in.