For years in most states, Medicaid eligibility had been limited to disabled adults, seniors needing long-term care and very low-income parents with their children.
Then along came the Affordable Care Act. It was designed to grow health insurance coverage across the board. One of its tenets was to expand Medicaid coverage beyond the extremely poor and disabled to include all adults earning up to 138 percent of federal poverty levels.
But in 2012, the Supreme Court gave states the chance to opt out Medicaid expansion.
Illinois is one of 25 states that went ahead with expanding the program. Neighboring Missouri did not.
We looked into the impacts of those differing decisions. Here’s what we found out.
In the fall of 2013, patient Steven Glispie was in his room at Touchette Regional Hospital in Centerville, just across the Mississippi River from St. Louis. Glispie has Type 1 diabetes.
“My insulin costs too much, so it’s hard to get, at the moment,” Glispie said. “So when I ran out, I had to, you know what I’m saying, go to the hospital.”
Glispie worked odd jobs, and didn't have health insurance through an employer. He couldn't afford to buy insurance on his own. And because he was only 27 years old and didn't have any children, he hadn't been eligible for Medicaid. “I had to go to the hospital,” Glispie said. “I had no other choice.”
Illinois expands its Medicaid program
Because Illinois opted to expand its Medicaid program under the federal health care law, Glispie was able to sign up for Medicaid coverage in October.
Angela Merten works at the hospital as an in-person "assister" under the Affordable Care Act. She helps people sign up for health insurance through the federal online marketplace.
From the computer in her office a few floors below Glispie’s hospital room, she talked him through his Medicaid enrollment over the telephone. The whole process took about 15 minutes.
But Glispie wasn't the only person Merten was helping. On her desk, was a stack of paper almost two feet high.
“Right now that stack ― that represents about 550 individuals who are uninsured, that I need to contact,” Merten said. “And quite honestly, most of them will be eligible for Medicaid under Illinois’ expansion program.”
That was back in October. According to the latest count, 200,000 Illinoisans like Glispie have enrolled in Medicaid under the Affordable Care Act.
Mike Claffey is a spokesman for Illinois on matters related to the ACA. He said all those new Medicaid sign-ups do not add up to a big new financial burden for the state. “One of the great things for states that opt into the Medicaid expansion is the very generous federal match that comes with it,” Claffey said.
That “generous federal match” means the feds will cover all the costs of Medicaid expansion for the first three years of the program, and at least 90 percent of the costs after that. For Illinois, that adds up to a whole lot of federal dollars coming into the state to cover health care for the poor. “We estimate from 2014 to 2020, we’ll tap about $12 billion in federal funding,” Claffey said.
Missouri opts out
Across the river in Missouri, many state legislators have a very different take on the economics of Medicaid.
Like many other Republicans, Missouri Rep. Jay Barnes thinks the existing Medicaid system has major problems. “It is on a path fiscally that is unsustainable for our state and country,” said Barnes, of Jefferson City.
Barnes said he’s not willing to consider expanding the state’s Medicaid program to cover more people until those problems get fixed. “What I’ve proposed to do is give Missouri the most market-based Medicaid system in the entire country,” Barnes said.
In other words, Barnes wants Medicaid to work more like private-sector insurance, and for Medicaid recipients to have to pay for some of their health care costs. “The intent being, every time a participant would show up for health care outside of preventive care, they’d have to make a cost-conscious decision,” Barnes said. “And they’d realize, hey, you know what, this is not free. It costs money.”
But even though Barnes and others in the Missouri legislature have proposed various options for reforming Medicaid, it’s unclear whether any of them will pass this session.
That’s not what St. Louis resident Sherri Coop wants to hear when it comes to Medicaid expansion. “How can it not be on our agenda in Missouri?” she asked.
Coop has personal experience with Medicaid. She used to be enrolled, but was dropped from the program for making too much money: about $600 a month.
Missouri’s Medicaid income limits are among the lowest in the country: a single mother with one child has to make less than $3,000 dollars a year to get coverage. And, unless they’re over 65 or disabled, adults without dependent children can’t qualify at all, no matter how poor they are.
Last year, Coop ended up in the emergency room with a life-threatening infection. She couldn’t work for two months, so she lost her job.
She said there was no way she could have afforded the hospital bill.
“The people who are in social service there are trying to find a way to help me get that covered, because I have no way to pay for it,” Coop said.
Missouri loses — and rejects — federal health care funding for the poor
Hospitals receive federal funds to help them pay for treating uninsured patients like Coop.
But under the federal health care act, that funding will start to go away.
Dave Dillon, who’s a spokesman for the Missouri Hospital Association, said over the next six years, Missouri’s hospitals will lose $4 billion in federal payments. The Affordable Care Act was designed to offset those reductions with more insurance coverage.
“In essence, the people who couldn’t pay before would have insurance, whether that is Medicaid or commercial insurance through the new marketplace,” Dillon said. “And therefore hospitals would have a significant reduction in basically charity care and bad debt that is associated with caring for the uninsured.”
If Missouri doesn’t expand its Medicaid program, it will also forgo the billions of federal dollars that would have come into the state to pay for that expansion.
The health insurance “coverage gap”
Even without Medicaid expansion, some low-income Missourians can still buy insurance through the federal online marketplace. In fact, those making between 100 and 400 percent of federal poverty levels ― or between $11,670 and $46,680 a year for an individual ― get a break on their premiums.
But there’s a very big catch. The poorest Missourians ― the ones making less than $11,670 ― have to pay full price to buy insurance through the online marketplace.
Ryan Barker, vice president of health policy at the Missouri Foundation for Health, said that's because the Affordable Care Act was designed with the expectation that all states would expand their Medicaid programs to cover all low-income adults. But in many states, including Missouri, that hasn't happened. “And for people making less than $12,000, that’s pretty unreasonable to expect that they could afford the full price of health insurance,” Barker said.
According to a study by the Kaiser Family Foundation, more than 193,000 Missourians fall into what Barker and others call the “coverage gap:” they’re not eligible for financial help to buy insurance through the online marketplace, they can’t qualify for Medicaid, and paying full price for health insurance just isn’t feasible.
Unless Missouri’s Republican-majority state legislature can come up with a politically-acceptable way to expand Medicaid coverage, Barker said the poorest Missourians will continue to have no real health insurance options.
Follow Véronique LaCapra on Twitter: @KWMUScience