In Republican States Like Missouri, Medicaid Expansion Still Faces Stiff Opposition

Six years ago, 53-year-old Corla Morgan noticed blisters forming on her neck and back.

“I couldn’t sleep because when I took my shirt off, if my shirt touched my skin, the skin just peeled off,” Morgan says. “I was in really horrible pain.”

Eventually she was diagnosed with nonmelanoma skin cancer, but that took a while—years, actually—because other than some trips to the ER she wasn’t going to the doctor. She couldn’t afford it.

Medicaid expansion was meant to cover people like Morgan. She’s too sick to work now, but even when she wasn’t, the jobs she pieced together didn’t pay enough for her to buy insurance.

“I was working two jobs just to keep my bills half paid,” she says.

And because Missouri chose not to expand Medicaid under the Affordable Care Act, an able-bodied adult like her doesn’t qualify without a dependent child.

More than 2.5 million Americans who would have been covered by Medicaid expansion were left uninsured in the 19 mostly-Republican states that rejected it. Now, following the GOP’s failure to repeal the Affordable Care Act, some of those states are revisiting the decision.

Renewed Efforts For Expansion

The governors of Georgia, North Carolina and Virginia have each said they are open to exploring the idea of Medicaid expansion. In Maine, a referendum on expansion will be on the ballot this fall. The biggest push so far, though, came in Kansas, Missouri’s neighbor to the west.

Kansas’s Republican-majority legislature voted for expansion in late March. But when the state’s Republican Governor vetoed the legislation, lawmakers came up a few votes shy of being able to override the veto. That’s in a state where Medicaid expansion had majority support.

In Missouri, opposition is much stronger. That has Democrats like state Representative Martha Stevens frustrated.

“It’s really a shame that we have not brought our federal dollars that we’re sending to D.C. back home to cover people,” Stevens says.

The federal government would pay at least 90 percent of the cost of expansion, which would bring about $2 billion into the state each year. Stevens says Missouri is just leaving that money on the table.

“Missouri is experiencing a huge budget crisis right now and we have an opportunity to bring in millions of dollars into our state budget to cover folks for healthcare,” she says.

Last week, the Missouri House voted down a proposal to expand Medicaid 102-41.

Caught in Political Crossfire

When the Affordable Care Act was passed, Medicaid expansion was never supposed to be optional. Actually, it was meant to be a cornerstone of the healthcare law. But when the U.S. Supreme Court upheld the law in 2012, it also ruled that states could not be required to expand the program.

That ruling, according to Heather Howard, a public affairs lecturer at the Woodrow Wilson School of Public & International Affairs at Princeton, made Medicaid expansion susceptible to heated state politics.

“A lot of people thought [those political battles] had to do with President Obama. And so some people thought that after this most recent election, the politics would cool and states could expand Medicaid,” Howard says.

But that hasn’t happened, and Howard says that’s because many Republicans are now focused on controlling Medicaid spending altogether. That’s true on the national level, as well as the state level.  Missouri state Representative Scott Fitzpatrick, who chairs the Missouri House Budget Committee make a fiscal argument against expanding.

“We’ve had to cut over $500 million of spending from [this year’s] budget to essentially make room for growth in Medicaid,” Fitzpatrick says.

He says expanding the program would make things worse. Even with the federal funds for expansion, Fitzpatrick says Missouri would still be on the hook for another $200 million a year.

“In a year where we are already cutting a lot of money out of higher education and other things in the state to pay for Medicaid growth, I don’t see us coming up with an extra $200 million,” he says.

Plus, there’s still a chance the U.S. Congress will take another stab at passing a major health care bill.

“I don’t think this is the [legislative] session in which we’re going to make knee-jerk reactions about expanding Medicaid,” Fitzpatrick says.

Cost of Care

Even without expansion, though, taxpayers still subsidize healthcare for the poor. Missouri hospitals provided $1.2 billion in uncompensated care in 2015, the most recent year the data is available. Hospitals don’t just eat that debt. There are local, state and federal funds that offset part of the costs, and a lot of what’s left is passed on to patients who do have insurance.

When the 2016 uncompensated care numbers are tallied, it will include the charity care Corla Morgan is receiving.

She’s been going to the hospital for painful treatments “at least three times a week for months,” she says. And those treatments will continue for the foreseeable future.

“It just seems like the state don’t want to help and it makes you feel like you’re nobody,” Morgan says.

Fighting back tears, she adds, “I’m about ready to give up.”

This story was produced by Side Effects Public Media, a news service covering public health.

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