Representatives from multiple ambulance services gathered Tuesday in the parking lot of the Missouri Primary Care Association in Jefferson City to express support for Amendment 2.
Theirs are among more than 265 organizations statewide that have endorsed the amendment as its Aug. 4 election day nears.
Missourians will go to the polls to decide "a very important question," said Jack Cardetti, spokesman for "Yes on 2," the campaign to push Medicaid expansion across the finish line in Missouri.
"Are we going to be the 37th state in the country to expand Medicaid?" Cardetti asked at a rally outside the association. "To bring a billion dollars of our own tax dollars back from Washington, D.C., back to Missouri communities?"
Missouri is one of 14 states that have not agreed to expand Medicaid to include people up to 138 percent of the poverty level. A successful initiative petition in Missouri got the issue placed on the November ballot, after which Gov. Mike Parson scheduled the vote for August.
Expansion would add approximately 230,000 people to the state's Medicaid program, MO HealthNet, which already serves about 900,000 people.
"Are we going to try to keep Missouri hospitals open? And are we going to protect thousands of front-line health care jobs?" Cardetti asked.
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Medicaid expansion is one of few policy issues across the state that business leaders and organized labor both endorse.
For many, a key issue surrounding Medicaid expansion is how it would support rural hospitals, he said.
Since 2014, 10 rural hospitals across Missouri have changed. That has a massive effect on health care in communities, Cardetti said.
Multiple emergency medical service organizations across the state were on hand Tuesday morning to announce their endorsement for Medicaid expansion.
"Nobody knows better what it means to have to transport a patient an extra 45 minutes when a hospital closes than some of the people sitting here with us today," Cardetti said. "Far too many people across the state are not getting the preventative care they need."
They wait until they have an emergency and have to call EMS drivers to take care of their emergencies, he said.
Oregon County remains one of the poorest and unhealthiest counties in the state, said Kenneth McKenzie, of the Oregon County Ambulance District. But, being a border county (along the southern border with Arkansas), the district sees first-hand the benefits of expansion have had in Arkansas, he said.
In Oregon County, there is an 11.6 percent uninsured rate, McKenzie said. Of those, only 2.4 percent have the ability to pay their bills, he said.
"Even though they're on some type of pay plan, they do not qualify for Medicaid because they make too much money," McKenzie said. "So (expansion) is for those working folks that are either not offered insurance or are above the federal poverty line and do not qualify for Medicaid."
Expansion would direct about $60,000 annually to the ambulance district. It currently writes off about $250,000 in bad debt.
Expansion would help not only the district, but the residents of the county, he said.
"These are the people that are seeking help at the last minute — when they are extremely sick," McKenzie said. "When they do seek help, they're not able to pay for it."
That's devastating to businesses and the community, he said.
Nicole Linhardt, with Osage County EMS, said there are people dealing with the loss of health coverage who still need medical treatment, but the department has an obligation to take care of them.
"We never ask for any insurance information. It doesn't matter what the coverage is," Linhardt said. "It's just the right thing to do."
Maybe expenses aren't covered or the district isn't covered.
"It's always about the welfare or the well-being of the person, not necessarily the coverage they have," she said.
Independent studies, including an analysis from the Missouri State Auditor's Office, have concluded that annual savings in the state budget resulting from Medicaid expansion are expected to reach $1 billion by 2016, Cardetti said.
A few hours after the rally, the Missouri House of Representatives' Budget Committee held a hearing on the fiscal note the Auditor's Office provided for possible expansion of MO HealthNet.
The office reported a range on what Medicaid would cost to how much it would benefit the state. That range was a cost of $200 million annually to a benefit of $1 billion annually.
Matt Powers, of Health Management Associates, testified that the organization studied the outcomes for three other states to determine how Missouri might fare if it were to expand Medicaid.
The HMA study looked at Arkansas, Indiana and Ohio specifically because they are politically "red" states, much like Missouri, Powers said.
Powers said he's worked most of his life to put together state- and local-driven health care infrastructures and tried to design sustainable programs and put incentives "in the right place."
State governments have the freedom to implement programs that fit their needs, he said.
"I respect that there are a lot of chess pieces," he said, adding the previous 21/2 hours of testimony illustrated how complex the process is. "Those chess pieces do need to be lined up to make it work, and it's hard work, but it can be done."
Each of the states customized their programs to keep costs under control and capture dollars available for them to help fund expansion, Powers said.
States that synchronized their programs correctly saw savings, he said.
"If you run a responsible program, people will support it," he said, adding expansion leads to jobs and economic development.
State Rep. Curtis Trent, R-Springfield, asked Kincaid what would happen should the federal government decide to stop providing a 90 percent match for Medicaid spending on the people added to MO HealthNet through expansion. As part of the Affordable Care Act, the federal government pays 90 percent of new recipients' Medicaid expenses. States that expanded Medicaid in the first few years of the program received 100 percent from the federal government.
Powers responded that states have the option of backing out of the program if the federal government were to cut the percentage it pays.