After weeks of rising COVID-19 cases, Missourians on Tuesday voted for the state to become the 38th in the U.S. to expand its Medicaid program, allowing Missourians to qualify for Medicaid, also known as MO HealthNet, based on income alone. 

“Yes” on Amendment 2 received 53.3% of the vote. It’s now the sixth Republican-led state to expand the program via ballot measure. 

But not all Missourians supported it. Although Medicaid expansion has potential to help rural hospitals, more than nine of which have closed since 2014, rural Missouri communities overwhelmingly voted against it.

A majority of votes in favor of expansion were concentrated in the eight urban counties in Kansas City, Columbia, Springfield and St. Louis areas. All other counties had higher percentages of voters who were against the expansion. 

The expansion won’t go into effect until July 2021, potentially leaving thousands still without health coverage in the midst of a global health crisis and high unemployment as a result of that crisis. COVID-19 cases rose 9.9% in the last week, with more than 55,000 total reported cases and 1,335 total deaths in Missouri. State unemployment is at 8% as of June 2020. It was at 3.5% in January, prior to the pandemic.

In 2010, the Affordable Care Act required states to expand their Medicaid programs to cover adults with incomes up to 138% of the Federal Poverty Level — roughly $17,609 a year. That requirement was then made optional with a 2012 Supreme Court ruling. Through this expansion, the federal government pays for 90% of the costs, with the state paying for the rest. 

Currently, people that are eligible for Medicaid include low-income children and their parents, pregnant women, and blind or disabled individuals. Adults 65 or older are also eligible. Adults without children at home are not eligible.

Growth and cost of expansion

A 2019 study from Washington University in St. Louis before the pandemic estimated that over 200,000 people would enroll in the program if expanded. About 6.1 million people live in Missouri.

Missouri Gov. Mike Parson’s office says there are 94,000 new Medicaid recipients as a result of COVID-19, partially because the Department of Social Services has been unable to “redetermine recipients’ eligibility.” Data from Georgetown University tracking Medicaid enrollment found a 9 percent increase in Missouri between February and May 2020 — one of the largest increases across the country

“There is no reason for us to leave that many people in our state without health care coverage,” Sly James, former mayor of Kansas City, Mo., told The Beacon. 

“There is no reason for us to abandon our rural community with their health needs by watching hospitals close because they cannot stay open. I think it’s going to help people in rural communities so they don’t have to drive one or two hours to take care of someone with a heart attack.”

A spokesperson for Gov. Parson, who is up for re-election in November, told The Beacon that Missouri can’t afford the Medicaid expansion, saying Medicaid already makes up 24% of the state’s general revenue budget, and that because of COVID-19, there’s already a strain on the budget. The office estimated the cost of the expansion to be around $170 million annually. 

The Washington University report from before the pandemic estimated that expansion would likely be budget neutral — creating cost savings of around $39 million. 

“Although we will live with coronavirus even after there is a vaccine, the chance that the coronavirus would have the same influence mid-next year, the same level of damage and health care need, as this is implemented, is less,” said Dave Dillon, a spokesperson for the Missouri Hospital Association, which supported expansion. 

“To assume that just because we’re at a place where a greater number of people would qualify we will lock in a larger number of people doesn’t make sense.”

Rural AND urban divide

Despite Medicaid expansion garnering less support from rural residents, rural hospital workers and trade groups like the Missouri Hospital Association, the Missouri Association of Rural Health Clinics, and the Missouri Rural Health Association advocated for the Medicaid expansion.

“Because the hospital’s mission is to support community health, because federal law requires anyone at a hospital emergency department to receive stabilizing treatment, and because we have a huge gap in the insured population, especially at lower levels of income, that contributes to a huge amount of uncompensated care for hospitals,” said Dillon with the Missouri Hospital Association. 

In 2018, Missouri hospitals provided $1.5 billion in uncompensated care. Giving more patients access to Medicaid through the expansion would help hospitals recoup some of these costs, supporters say.

“Every one of the 10 rural hospitals that have closed down have listed the lack of Medicaid expansion as one of the reasons they are having to see all of these people who are uninsured,” said Jay Hardenbrook, Advocacy Director for the Missouri AARP. 

“They’re really not getting paid at all, where with Medicaid expanded, they have a health insurer to pay those charges. We have membership in every county, and we’re hearing from folks how difficult it is to get health services in rural Missouri.”

The Missouri Farm Bureau, which represents more than 134,000 member families across the state, advocated against Amendment 2, citing concerns over the budgetary costs.

“There are things that are underway that would achieve the same goals of access and affordability for more Missourians,” said Leslie Holloway, a senior director of regulatory affairs for the Missouri Farm Bureau. “We do not support putting more money into the Medicaid program, which we already know is bankrupting states and rural hospitals in its current form.”

The Farm Bureau said it is dedicated to improving health care in rural areas through other means, like broadband and telemedicine access and expanding the authority of physician assistants and nurse practitioners. 

“This isn’t a budgetary issue as much as an ideological issue,” James said. “There are now 38 states, including Missouri, that have expanded Medicaid. I haven’t seen any of them go bankrupt.”

Brittany Callan is the health and environment reporter at The Beacon and a Report for America corps member. You can reach Brittany at brittany@thebeacon.media. Funding for this reporting was provided in part by the Health Forward Foundation.