Newsletters

POSTED: July 31st, 2020
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, July/August 2020,

Written by: Sarah Berg, MD, Resident, Department of Emergency Medicine, Washington University, Wash U Board Representative to MOCEP

Brandon Drazich, MD, Resident, Department of Emergency Medicine, Washington University and MOAAEM Resident Representative

Healthcare access is an ongoing problem in Missouri. In the safety net emergency department, we see every patient, regardless of their insurance status. Imagine if most of the patients that walk through our front doors had insurance. We could provide all the testing and treatment they need without causing undue anxiety about the astronomical costs of healthcare today. We could guarantee follow up with primary care and specialist providers. We could rest assured that they are able to purchase their beta blocker, antibiotic, or inhaler when they leave the hospital, hopefully preventing them from coming back with a hypertensive emergency, severe sepsis, or status asthmaticus, due to lack of medication access.

Medicaid expansion is a hot topic in Missouri this summer that will be voted on by Missourians on August 4th. Two political action committees, Healthcare for Missouri and Missourians for Healthcare, cultivated signatures in support of adding Amendment 2 to Article IV of the Missouri Constitution and placing it on the ballot in 2020.¹ Originally slated for the November 3rd election, Governor Mike Parson moved the vote to the primary ballot in August, arguing that the state would need as much time as possible to prepare funding for the measure if it is approved.²

Medicaid was established in 1965 as an addition to the Social Security Act, which established the welfare system to benefit the elderly, blind, dependent children, mothers, and people facing unemployment and disability.^3,4 Prior to the creation of Medicaid, the federal government made limited payments to states to help offset the costs of acute healthcare services purchased on behalf of public assistance recipients, but the services varied widely from state to state. At its outset, Medicaid provided acute care services to public assistance recipients. In the last five decades, Medicaid’s role in the United States has changed dramatically, but its essential purpose, to provide healthcare coverage to the least fortunate citizens, remains the same.⁵

In 2019, Medicaid was responsible for the healthcare coverage of 75 million people, or approximately 1 in 5 Americans.⁶ In Missouri, Medicaid provides coverage to all people who are blind or totally disabled as well as to eligible low income seniors over 65, adults with dependent children, infants under age one, children ages one to 18, and pregnant women. It does not cover adults without dependent children. Adults with dependent children are covered only if they earn a household income of up to 22% of the federal poverty level, or an annual income of about $5,500 per year for a family of four in 2019.⁷ Medicaid is responsible for about 50% of long term care payments,⁸ and is jointly financed by the federal government and the state. All states are guaranteed at least 50% matching by the federal government.⁹ For fiscal year 2021, Missouri will receive 64.96% match for Medicaid expenditures.¹⁰

The landscape of healthcare coverage changed in 2010 when the Patient Protection and Affordable Care Act (ACA) was passed by Congress and signed into law by President Obama.¹¹ The law expanded Medicaid to all Americans making up to 138% of the Federal Poverty Level. It established 10 “Essential Health Benefits,” such as preventative services, assistance for substance use disorders, and mental health coverage, most of which are guaranteed to be covered by Medicaid.

In 2012, the Supreme Court heard the case “National Federation of Independent Businesses, et al v. Sebelius”, which ruled that the federal government could not legally mandate states to expand Medicaid.¹² Medicaid expansion became a choice in the states, and Missouri chose not to expand. The political climate in 2012 likely contributed to Missouri’s decision. Politicians then and now claimed that Missouri would have to re-allocate funds from education and public safety or would have to raise taxes in order to pay for Medicaid expansion.^2,13 However, the ACA ensured that states would not have to come up with money for Medicaid expansion on their own. In fact, from 2014 to 2016, the federal government provided 100% matching for payments on newly eligible Medicaid beneficiaries. In 2020, the federal government continues to provide states with 90% matching for Americans newly eligible for Medicaid, and the 90% match rate will continue indefinitely for these citizens.⁶ Federal taxes paid by Missourians currently fund these payments received by other states.¹⁴ Additionally, the ACA decreased funds allocated for Disproportionate Share Hospitals (DSH) funding. DSH was established in 1985 to provide more money to hospitals who see a higher proportion of patients who are uninsured or underinsured to offset the cost incurred by hospitals to provide care to those patients.¹⁵ The ACA aimed to reduce DSH payments by 2020, arguing that hospitals would see a higher proportion of patients with Medicaid and fewer proportion of patients without insurance, and would therefore need fewer DSH payments.¹⁶ Unfortunately, without Medicaid expansion ensuring more guaranteed coverage for Missourians, hospitals in Missouri will miss out on both fronts.

On August 4, Medicaid expansion will appear on the statewide primary ballot.¹⁷ A yes vote will expand coverage to people 19 to 64-years-old with household income at or below 133% of the federal poverty level. This group is largely excluded from current Medicaid coverage and make up a large portion of uninsured and underinsured Missourians. Amendment 2 would also prohibit increasing specific requirements to newly eligible Medicaid beneficiaries, such as drug tests or employment requirements that are not required of current Medicaid beneficiaries. The measure encourages use of federal funds available for Medicaid expansion over any state funds, thus decreasing the burden on Missouri to fund expansion.

Since 2010, 37 states have expanded Medicaid, including Arkansas, Illinois, and Iowa.¹⁸ Studies conducted since the enactment of the Affordable Care Act show improved access to healthcare for newly eligible Medicaid beneficiaries.¹⁹ These patients are less likely to postpone care and less wary of the healthcare system. They are empowered to improve their overall health, which improves wellbeing and makes for more productive citizens. Medicaid beneficiaries are overall satisfied with the care they receive. States have demonstrated increased access to prenatal care for low income pregnant women, reduced child and teen mortality, and higher childhood achievement. Early studies also show overall savings on healthcare expenditures in states that have expanded Medicaid, and no state has reversed their decision to expand.

One study conducted by Washington University in St. Louis estimates that Medicaid expansion would bring more than $1 billion in federal taxes back to Missouri each year.²⁰ These taxes are already earmarked for Missouri, but are going to states that have expanded Medicaid. Missouri would save $39 million in the first year of Medicaid expansion alone by replacing state funding for healthcare of low income individuals.²¹ A study by the Missouri Foundation for Health estimated Medicaid expansion in Missouri would lead to an increase in 16,330 jobs, with 63.7% occurring outside of the Kansas City and St. Louis metropolitan areas. The study estimated an increase in the size of the state economy of $2.5 billion in economic output and $1.6 billion in gross domestic product.²² Nearly 40% of Missourians live in rural communities, and since 2016, 10 hospitals in rural areas in Missouri have shuttered their doors. An additional 26 hospitals are considered “vulnerable to closure.”²³ The Missouri Hospital Association has advocated for Medicaid expansion in part because the group believes the increased funding will help keep rural hospitals open for the patients that desperately need them.²⁴ The measure is also supported by the Missouri State Medical Association, the Missouri Emergency Medical Services Association, the Missouri Nurses Association, most of the largest healthcare organizations in the state, and by MOCEP.²⁵

Medicaid expansion benefits our patients, our hospitals, healthcare providers, and all Missourians. We are duty bound by the ethics of our profession to promote the greatest good for the greatest number of people, to uphold beneficence and reject malevolence. We are also bound by the law to provide care to all people that cross the threshold of our emergency departments, regardless of their ability to pay. There should be no doubt that Medicaid expansion in Missouri will improve the health and wellbeing of a large portion of our patients.  Please vote “yes” on Amendment 2 on August 4th.

Sources:

1. (n.d.). Missouri Amendment 2, Medicaid Expansion Initiative. Retrieved July 25, 2020, from https://ballotpedia.org Missouri_Amendment_2,_Medicaid_Expansion_Initiative_(August_2020)
2. Ballentine, S. (2020, May 27). Parson moves up vote on Missouri Medicaid expansion. AP NEWS. https://apnews.com/370412b64934d5f8a2db21131d3d1485
3. History | CMS. (ed. 2020, January 13). Centers for Medicare & Medicaid Services. https://www.cms.gov/About-CMS/Agency-Information/History
4. Medicaid: A Brief History of Publicly Financed Health Care in the United States. (2019, January). Center For Health Care Strategies. https://www.chcs.org/media/Medicaid-Timeline-Fact-Sheet_01.14.20v2.pdf
5. Stanton, G et al. (2017, February 21). A Brief History of Medicaid. ASPE. https://aspe.hhs.gov/report/using-medicaid-support-working-age-adults-serious-mental-illnesses-community-handbook/brief-history-medicaid
6. Rudowitz, R., Garfield, R., and Hinton, (2019, March 6). 10 Things to Know about Medicaid: Setting the Facts Straight. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/
7. Kaiser Family Foundation. (2019, October). Medicaid in Missouri. KFF. http://files.kff.org/attachment/fact-sheet-medicaid-state-MO
8. Reaves, E. L. and Musumeci, M. M. (2015, December 15). Medicaid and Long-Term Services and Supports: A Primer. KFF. https://www.kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/
9. Rudowitz, R., Orgera, , and Hinton, H. (2019, March 21). Medicaid Financing: The Basics – Issue Brief – 8953-02. KFF. https://www.kff.org/report-section/medicaid-financing-the-basics-issue-brief/
10. Office of the Secretary, Department of Health and Human Services. (2019, December). Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the Children’s Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2020 Through September 30, 2021. DHHS. https://www.govinfo.gov/content/pkg/FR-2019-12-03/pdf/2019-26207.pdf
11. United States. (2010). Compilation of Patient Protection and Affordable Care Act: as amended through November 1, 2010 including Patient Protection and Affordable Care Act health-related portions of the Health Care and Education Reconciliation Act of 2010. Washington:U.S. Government Printing Office.
12. National Federation of Independent Business v. Sebelius. (n.d.). Oyez. Retrieved July 25, 2020, from https://www.oyez.org/cases/2011/11-393
13. Crisp, E. (2012, July 1). Missouri legislative leaders saying no to Medicaid expansion. St. Louis Post-Dispatch. https://www.stltoday.com/news/local/govt-and-politics/missouri-legislative-leaders-saying-no-to-medicaid-expansion/article_76ee8236-5591-551b-940d-031a178d61a6.html
14. Healthcare for Missouri. (n.d.). How a Medicaid Expansion Ballot Measure Benefits Missouri. YES on 2 – Healthcare for Missouri. Retrieved July 25, 2020, from https://www.yeson2.org/learn-more#
15. Centers for Medicare & Medicaid Services. (2020, May 11). Disproportionate Share Hospital (DSH) | CMS. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/dsh
16. Congressional Research Service. (ed. 2020, April 1). Medicaid Disproportionate Share Hospital (DSH) Reductions. https://crsreports.congress.gov/product/pdf/IF/IF10422
17. Office of the Missouri Secretary of State. (n.d.). 2020 Ballot Measures. Missouri Secretary of State. Retrieved July 25, 2020, from https://www.sos.mo.gov/elections/petitions/2020BallotMeasures
18. Kaiser Family Foundation. (2020, July 1). Status of State Medicaid Expansion Decisions: Interactive Map. KFF. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
19. Guth, M., Garfield, R., and Rudowitz, R. (2020, March 17). The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. KFF. https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/
20. Center for Health Economics and Policy. (2019, February). Analysis of the Fiscal Impact of Medicaid Expansion in Missouri. Institute for Public Health at Washington University. https://publichealth.wustl.edu/wp-content/uploads/2019/02/Analysis-of-the-Fiscal-Impact-of-Medicaid-Expansion-in-Missouri-IPH.pdf
21. Huang, K. et al. (2019, September). Effects of Medicaid Expansion on Coverage, Access, Outcomes, and Costs: Implications for Missouri. Institute for Public Health at Washington University. https://publichealth.wustl.edu/wp-content/uploads/2019/09/Medicaid-Expansion-Brief-final-PDF.pdf
22. Evangelakis, P., et al. (2020, April). Economic Impacts of Increased Federal Funding in Missouri Associated with an Expansion of its MO HealthNet Program. Missouri Foundation For Health. https://mffh.org/wp-content/uploads/2020/06/MFH-MOHN-Expansion-Federal-Funding-Impact-Report-web2.pdf
23. Yes on 2 – Healthcare for Missouri. (2020, January). How Amendment 2 Benefits Missouri’s Health and Bottom Line. Healthcare for Missouri. https://mocep.org/wp-content/uploads/Yes-On-2-fact-sheet-6.9.pdf
24. Missouri Hospital Association. (2020, June 11). Medicaid Expansion Ballot Initiative. https://web.mhanet.com/article/8479/Medicaid-Expansion-Ballot-Initiative.aspx?articlegroup=2659
25. Yes on 2 – Healthcare for Missouri. (n.d.). Endorsements. Retrieved July 25, 2020, from https://www.yeson2.org/endorsements