Access to health care is one of the key issues facing the state legislature this session. With positions on the health care policy committee, two lake area representatives — Diane Franklin and David Wood — are digging into the topic sparked by federal health care reform and Gov. Jay Nixon's related push for Medicaid expansion.

Access to health care is one of the key issues facing the state legislature this session. With positions on the health care policy committee, two lake area representatives — Diane Franklin and David Wood — are digging into the topic sparked by federal health care reform and Gov. Jay Nixon's related push for Medicaid expansion.

The proposal

Under health care reform, the federal government is promoting expansion of Medicaid to cover a potential gap in coverage between the current level of Medicaid and the level required to receive federal premium tax credits through the Affordable Health Care Act.

The health care reform law would provide new federal premium tax credits to Missourians earning 100 between 400 percent of the FPL - about $11,000-$45,000 for one person and $19,000-$77,000 for a family of three. These tax credits would be provided so that recipients can purchase sliding scale individual health insurance plans through Health Insurance Exchanges if the individuals and families don't have access to affordable employer-sponsored coverage.

Currently, Medicaid in Missouri covers low income children, pregnant women, people with disabilities who are unable to work, seniors and very low income parents.

The eligibility for low income parents is set at 19 percent or less of the federal poverty level (FPL). Eligibility for the disabled is set at 85 percent of the FPL or less.

The federal proposal would mean extending coverage to working parents, working adults without children and Missourians with disabilities earning 138 percent or less of the FPL.

The relation of FPL to actual income varies depending on the number of people in a family.

The federal government is offering to cover 100 percent of the cost of expansion from 2014-2016 with a reduction down to 90 percent by 2020.

The need

A study through the Missouri Budget Project predicts the state will have 959,820 uninsured by 2014 with 369,738 being estimated to be non-elderly adults living on less than 138 percent of the FPL. The projected number of new non-elderly adults that would be covered under the expansion is 267,306.

Based on 2010 U.S. Census data, the study estimates that 22.9 percent of Morgan County's population is currently uninsured - 3,624 out of a total population of 15,850. It has the fifth highest rate of insured residents in the state, following Scotland, Knox, Taney and Ozark counties.

This data also showed that Morgan County had 5,419 persons living under 138 percent of the FPL. Approximately 31.4 percent - 1,699 - of that total were uninsured.

Based on U.S. Census data, Camden County has an uninsured rate of 18.7 percent - 6,355 of 34,053. Its population living under 138 percent of the FPL totaled 8,538, of which about 31.8 percent were uninsured.

Miller County's uninsured population totaled 3,758, about 18.2 percent of its total population. It showed that 6,604 residents were living under the 138 percent line with around 26.2 percent of that population being uninsured.

The potential impact

The study, completed by Dr. Timothy McBride of Washington University, Sidney Watson, J.D. of St. Louis University School of Law and Amy Blouin of the Missouri Budget Project, states that the extension would significantly reduce the number of uninsured in the state as well as bring more money into the state's economy.

It estimates around 267,000 previously uninsured Missourians would be covered, a possible statewide reduction of the uninsured population by 28 percent.

Overall, the study predicts that the expansion would increase the Medicaid roll by more than 267,000 with the "most dramatic impact" on rural areas which have a larger proportion of its population uninsured due to lower rates of employer-sponsored insurance, more residents living in poverty as well as other factors.

Southwest Missouri — of which the lake area is a part — is estimated to see an increase of 60,564, a reduction of 29 percent of the uninsured.

The study states that Morgan County is one of 21 rural counties where 10 or more percent of the population would be eligible for the expanded coverage. In Camden County, 8.9 percent would be eligible and 4.5 percent would be eligible in Miller County.

The study also says that the expansion would bring approximately $1.56 billion into the state's economy in 2014 via new federal health care matching funds, similar to a major new corporation coming to the state. Given the assumption that a higher percent of the rural population would benefit from the expansion, the study says the economic impact would also be proportionally greater in these parts of Missouri.

It should be noted that the Missouri Budget Project study on Medicaid expansion references other studies of the proposal - some show less impact and others more.

What the legislators say

Both Franklin and Wood agree that there is a need for better health care access in their constituencies. The two Republicans are unsure, however, whether the proposed plan would actually have the benefits that are being touted by Nixon and some studies.

The question of Medicaid expansion does not have a simple yes or no answer, says Franklin.

The legislature may be well into its session before it works through the issue, she says, but she predicts that Medicaid transformation will become the heart of the discussion rather than merely expansion.

Solvency and sustainability of the program as well as improved health care access are the goals, according to Franklin, who in her second term of office is the vice chair of the health care policy committee.

The committee is reviewing the current system and the proposal - efficiency and real-life health care access.

"We have to look at how it (expansion) will affect Missouri taxpayers and the average consumer of health care," she says.

The two legislators are concerned about just what the expansion will support.

"I think Missouri likes to keep its tax burden low and bureaucracy at a minimum," Franklin says.

She questioned whether the program would really support more actual health care access or whether it would just increase the bureaucracy of the industry.

In the health care field, one of the factors that limits availability, whether from a hospital, nursing home, clinic or pharmacy, is the reality of every business - the bottom line.

Whoever the provider is, explains Franklin, they have to employ people and buy goods and services at market price, yet on the reimbursement side they receive half of market price from programs like Medicaid.

"That equation just doesn't work," she says. "So a very important part of this discussion - if we want health care communities to provide, one of the questions we have to be able to answer is who makes up the difference between the cost versus what they're receiving. We have to be sure the program is developed in a way that encourages health care providers to stay in our area to provide health care."

Franklin cited a recent case in the lake area involving Medicare, similar in some aspects to Medicaid but for the elderly.

Westlake Medical Center is a non-profit clinic in Laurie where 85-90 percent of patients are on Medicare. The independent clinic is facing financial hardship due to its patient base in Medicare and is struggling to maintain providers as a result. The clinic will be down to one doctor in March and is seeking donations from the community to help recruit more providers and work towards becoming self-sustaining again.

Over the last decade, the federal government has bypassed the cuts indicated by Medicare's sustained growth formula and have simply allowed Medicare payments to physicians to remain close to the same from year to year. The reimbursement rate stays essentially flat while the American Medical Association indicates that costs have risen to provide care have risen 20 percent. One-third of Medicare clients struggled to find new primary care providers in 2011 as a result, according to the AMA, which is calling for an overhaul of the Medicare system.

The state legislative committee is also reviewing the efficiency of the current Medicaid system, such as getting patients to the appropriate providers of care.

"If it's not an emergency, then patients needed to be directed to the primary care level then moved through where they need to go. If someone has a cold and they enter a facility equipped for emergencies, that's an inappropriate use of taxpayer dollars - so it's a waste then," Franklin says. "We need to have a mechanism in place for programs like Medicaid that offer entry level for individuals."

Fraud and abuse of Medicaid is also a concern, according to Wood.

"You hear things. We need to carefully at fraud. I don't think it's rampant but it does exist. We need to clean up some things. I hate to see abuse of any program," he says.

The way Medicaid in Missouri has provided for the current level of users is not sustainable, she says, and the committee and legislature needs to work out how to transform it into a solvent system for the long term.

"In Missouri, we're like that. We don't go forward on something until we can see that it can work for us," Franklin says.

Many in the legislature question whether the influx of money into the state for services is sustainable with the national debt continuing to mount.

"In theory, it sounds like more health care - more clinics so more labs, employees, etc., but the question is can we afford it on the back side," says Wood.

He is cautious about relying on federal funding to support the system.

"Proponents say no money the first three years but you're putting a lot more people on the rolls when the federal government may or may not fully fund the program. If there's a shortfall — as we've seen in other programs — once you give a certain amount (of coverage), it's hard to take it away," he says. "We have to fiscally responsible as a state and ensure quality health care for citizens."

Right now, the 60/40 split between the federal and state governments to cover Medicaid is relatively stable, changing the equation is a bit of gamble, Wood says.

Even if fully funded the first three years, the state would still have to eventually come up with a 10 percent match of an unknown - but definitely higher than the current total - figure depending on how many really go on Medicaid as a result of the expansion.

Wood believes it may be significantly more than estimated, leading to a much higher bill for the state than expected.

In the interim three years, the 40 percent portion that the state now funds would be spent somewhere else. So the 10 percent match could mean cuts to other programs down the road, he says.

According to Wood, the federal government has already cut health care benefits to Missouri in a lot of ways, such as reductions in DSH (Disproportionate Share Hospital) payments, making the new funding a partial replacement under different mechanisms.

Though Wood agrees that some extension of the limit of Medicaid is needed, he is also concerned that the extent of the proposed expansion - up to 138 percent of the FPL - may be too far.

"Is there need in this area, at some level possibly, but 138 percent? It may make people think twice about looking for work or taking a promotion and raise. I don't want to create that situation," he says. "There's a great need for services. The expansion is in multiple areas. Some areas it may help, but other areas, I have great concerns, take it too high."

It's a complicated issue, but they are committed to finding answers, according to both legislators.

"We want to provide access to health care, but we have to do it in a common sense reasonable way. So that will take some examination. We all say we want everyone to have health care, but in the reality aspect of it, we have to be able to pay for it as well," says Franklin.