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Rain is drizzling on the roughly 40 people standing in line outside the Good Samaritan Care Clinic in rural Mountain View, Missouri. Some have been standing for hours. At 5:30 pm, the clinic doors swing open, and the patients flood into a clean, bare bones waiting room.
[Sound: staff processing files, talking]
One of them is Anita Sutherland, who drove 45 minutes to get here. She’s not covered by Medicaid now, but she would be if Missouri were to opt into the federal expansion. So would an estimated 300,000 other Missourians.
Until a few weeks ago, Sutherland was a home health aide who made less than $10,000 a year doing house chores and grocery shopping for elderly clients. Her job didn’t include benefits. So, no health insurance. She first came to this charity clinic in January because she was fainting on the job.
“I was bleeding so bad, I would have to take changes of clothes to change. But I was trying to take care of my patients, because I was responsible for them,” Sutherland said.
Her mileage driving to different towns was not reimbursed, and her time in the car wasn’t paid.
A volunteer doctor at this free clinic found that her blood levels were extremely low. He told her to get to a hospital. The nearest one was Poplar Bluff.
“They took me in the ER and said I needed some money before they would see me. So I said, ‘This is all I’ve got.’ It was my electric bill money. So, we gave them that. They went ahead and seen me, and admitted me, and I wound up getting four units of blood,” she said.
She says a specialist in Poplar Bluff refused to see her at a follow-up unless she could put down a $500 deposit. So she left, upset. She returned to Mtn. View, where a Mercy facility treated her, despite her inability to pay. There, a biopsy showed that Sutherland had ovarian cancer. An oncologist in Mercy Springfield treated her. The Mercy facilities swallowed the cost in so-called “charity care.”
Davidson: So, you make less than 10,000. That’s below the federal poverty level. And yet, you still, and many people like you, don’t qualify for Medicaid.
Sutherland: Yeah. It’s hurtful. Because you pay in all these taxes, and you work your butt off. And then, they’re like, “Bam. You can’t have it. We’re not helping you.” You feel like you’re at the point of no return. Because it’s just hard. Because you want to pay it, and you can’t. I don’t want charity. I’m not here for charity. That’s why I think a lot of people kill themselves. Because there’s no hope.”
Opting into the federal Medicaid expansion would raise the eligibility level from about 19 percent of the federal poverty level, where it stands now, to 138 percent. For a family of four, that threshold would jump sevenfold—from a household income of $4,475 a year to $32,499 a year.
Right now, Missouri does not provide Medicaid coverage to non-custodial adults, no matter how poor, unless they are disabled, low-income pregnant women, or seniors.
Under the expansion, individuals under 65 would be covered if they earned less than about $15,000 a year.
But paying for this expansion, at both the state and federal levels, is a major piece of the puzzle.
For the first three years, the federal government would pay 100 percent of the state’s Medicaid costs—in FY 2014, that’s just under one billion federal dollars, and closer to two billion for each of the next two fiscal years. In 2017, Missouri would pick up 5 percent of the tab, and gradually slide up to paying 10 percent in 2020 and onward.
Linda Luebbering, the state budget director, said that translates to the state paying 30 million out of its general revenue funds in FY 2017, and about 24 million from other state funds. In FY 2021, when the state begins paying its full 10 percent, Missouri would be paying 143 million of general revenue and 116 million from other state funds.
This clinic is in the district of Shawn Rhoads, a freshman Republican in the House of Representatives. Despite that the Chamber of Commerce and the only hospital in his district have endorsed the Medicaid expansion plan, Rhoads is still not sold.
Rhoads: “I wouldn’t be against expansion, if it was fixed. If there was reform, and if we fixed it—and I also think there are several legislators up here who feel the same way.”
Davidson: “So, when you say ‘reform,’ can you pinpoint specifically what reforms you would require before voting ‘yes’ on Medicaid expansion?”
Rhoads: “Sure. And that’s a big topic. There are a million ways to reform. There’s a private insurance-based program, which is what Arkansas, and I think Kansas have done, with a co-pay, or deductible. Even though it’s a very insignificant amount, it puts people with ‘skin in the game.’ They’re in charge of their own health care.”
Lawmaker Shawn Rhoads says he’s not absolutely against taking the federal dollars, but he wants to see the system improved first. Others, however, say under no circumstances, reform or no reform, will they support the Medicaid expansion under the Affordable Care Act, period.
“It’s fiscally not sound to expand Medicaid under the proposal of the ACA,” says Carl Bearden, a former lawmaker and the executive director of United for Missouri.
That’s a statewide organization with 70,000 members that emphasizes fiscal responsibility and limited government. He’s spent a lot of time talking to lawmakers about Medicaid recently, he says.
In 2005, Bearden voted for the legislation that dramatically cut the state’s Medicaid program because he felt the state couldn’t afford it. 100,000 people lost coverage and many more had their benefits reduced, but the state saved millions of dollars as a result.
Supporters of the Medicaid expansion say conservative lawmakers have turned it into a political issue—that the only reason why it’s been rejected is because it’s associated with President Obama’s health care law, or “Obamacare,” and that all this talk about reform is just a smokescreen.
But Bearden flat out rejects that: rather, the basis for his opposition, he says, is rooted in the federal debt.
“Most of the money that would be sent to Missouri is not taxpayer money being returned to Missouri, but actually is borrowed money, further increasing out debt, and increasing the obligations of future generations,” Bearden said.
Bearden says he would support legislation that fixed a broken Medicaid system, while working within Missouri’s budget. For example, Representative Diane Franklin’s bill earlier this year would have created a high deductible plan for people living at or below the poverty level, and would set up a co-pay program. That bill died before making it to the House floor.
Dozens of chambers of commerce have endorsed the Medicaid expansion plan—including those in Springfield, West Plains, and the Missouri Chamber of Commerce —saying that healthier workers lead to a more productive workforce. Hospital administrators say the expansion is imperative, and some faith leaders have rallied for the expansion, reminding lawmakers of the significant human element here.
There are some federally qualified clinics that offer a sliding scale fee for low income patients. But in south-central Missouri, one of the poorest Congressional districts in the nation, even those are expensive for a lot of folks here.
Back at the Good Samaritan Clinic, Anita Sutherland says she was raised with a strong work ethic, that you pay your own way forward with the sweat of your brow. But her hard work has yet to pay off. The cancer’s gone, but now she has lymphedema –swelling because of blocked lymph nodes.
In a few days, she’ll drive back to a cancer center in Poplar Bluff, a facility she says won’t treat her unless she pays up front. She tells me her refrigerator is empty tonight because she’s been saving up for that appointment. She’s saved enough for the specialist’s fee, she says, but she’s not sure she has enough for the bandages.
For KSMU News, I’m Jennifer Davidson.