Opting out of Medicaid Expansion: The True Cost to Missouri

Angela Schiefelbein FNP

4/27/2014

Years ago, I worked as a volunteer nurse in Angola, Africa, a severely impoverished country that had been at war for 35 years. Children died of malnutrition weekly, and there was little to no medicine to intervene for even the most basic health problems. When my patients had diabetes, high blood pressure, or pneumonia, all I could do was offer comforting words; there was literally nothing medically to offer.

As a Nurse Practitioner in the state of Missouri in 2014, I am now experiencing the same nightmare. Because of Missouri’s decision to not expand Medicaid for folks who can’t afford a health plan through the Affordable Care Act, every day I have to tell people with treatable, chronic illnesses what their care SHOULD look like – if they only had insurance. I suggest (not jokingly) that they move out of this state, because there is no care to be had in Missouri. I apologize to them that those of us with means don’t consider how horrible their realities must be, and I grieve with them as they struggle through that daily reality. 

It used to be a little little better for folks with low incomes. Up until last year, we had St. Louis Connect Care, a place where the under- or un-insured could get specialty care for issues like heart disease. It wasn’t perfect – there was still no psychiatric care, physical therapy (or a myriad of other specialty areas) available – but it offered a more reasonably priced option for care and tests like CT, MRI, or ultrasound. It was the only place where a person could get help that primary care couldn’t provide.

Connect Care is now shuttered, and now the ERs are providing emergency care for illnesses that could be treated better (both in terms of treatment-effectiveness and cost-effectiveness) in the primary care setting. Now the person making minimum wage with high blood pressure will go to the ER with a stroke in 6 months, rather than accessing care beforehand, because they can’t afford the preventative care.

It used to be better for pregnant women too. We know that prenatal care means healthier babies; it seems simple and civilized that every pregnant woman should get prenatal care. Last year we could get routine prenatal care for all women, regardless of their ability to pay. No longer. Because of the funding cuts from Missouri refusing to expand Medicaid, it isn’t possible to get regular, routine pregnancy care (including lab work, office visits, ultrasounds) for uninsured women for more than 8 weeks of their pregnancy. Here in the richest country in the world, we are triaging pregnant women to determine which 8 weeks during their pregnancy would be most effective to care for them and avoid devastating outcomes. It’s medically and ethically absurd. Missouri will start seeing the ramifications soon, in the increased number of premature and sick babies that will cost far more than the prenatal care ever would have.

We know that preventative care is cheaper than ER visits and ICU stays. Why did Missouri lawmakers refuse to expand Medicaid, knowing that this decision will cause immense suffering AND cost the public more? Rather than accepting funds to provide care for their constituents (by expanding Medicaid as is the plan with the ACA), the Missouri House has rejected the funding. It seems that they are drawing a line in the sand, taking their toys and going home, and causing massive suffering in the process. (These decision makers, by the way, have great health insurance.) I would like to bring them into the exam room with me as I tell patient after patient that – like my patients in Angola – that there is little I can do in the primary care setting to help treat their chronic illnesses.

One person I’d like them to meet is Suzanne, who has gout, high blood pressure, and osteoarthritis (and most recently and unsurprisingly, depression). She needs an rheumatologist to care for her severe gout, which, combined with her arthritis, makes it hard for her to move without a lot of pain. Suzanne does not make enough money to qualify for the Affordable Care Act – you have to make above 133% of the poverty line to qualify. Someone like Suzanne was supposed to be supported by her state expanding Medicaid, and since that didn’t happen, she can’t get either and has absolutely no options. And now that Connect Care has closed, Suzanne can’t get the specialty testing and care she needs. As her primary care provider, I have nothing to offer her except my apologies and my tears, because it is very hard not to cry with a patient in that much pain and for whom I can do very little. It makes me so angry. I wish these Missouri lawmakers would have to sit for five minutes with Suzanne and explain to her, while looking her in the eye, why expanding Medicaid isn’t a good idea. 

Or I might have them sit with Maria, another one of my patients. Maria was born in Mexico, came here without papers, and has lived here and raised her three children in St. Louis for the past 15 years. She (or someone like her) has washed your dishes, cooked your food, cleaned your hotel room or ironed your shirts for over a decade. She pays taxes, she volunteers at her church and at a food pantry. She is a really good Mom. I would have the lawmakers sit with Maria and explain why her 11 year old daughter can’t get the test that would determine the cause of the seizures she’s been having. I would have them sit at the bedside of her daughter after she has one of these seizures, try to hold her hand while they explain to Maria why it makes sense that she can’t get an EEG or surgery.

Lastly, I would have them sit with Shelly, who just lost her baby two weeks before the baby was due to be born. Shelly is devastated, and adding insult to injury, she will now spend the rest of her life paying off the hospital debt she incurred when she almost bled to death because she had placenta previa (a condition in which the placenta is too close to the cervix). This would have been easily detected by the ultrasound that Shelly could not afford, and appropriate preventative care could have been sought. As it is, Shelly will never have another child, and will mourn her daughter for the rest of her life. I would have them sit next to this 24 year old and explain why the decisions they are making are correct.

Perhaps I sound angry. I am very angry. I am embarrassed that health care in Missouri in 2014 resembles healthcare in a war-ravaged, impoverished country. We can do better. We must do better. And for those of us that are doing OK, that complain to the neighbors because our deductible is too high or our co-pays stretch our budgets, we need to realize that we are the fortunate ones. Our reality is NOT the reality of the many of our fellow Missourians. And while this is anyone’s reality, none of us are truly thriving. And many of us, our neighbors, our relatives, our friends, are suffering greatly and needlessly every day.