Missouri residents have had an ongoing summer invitation by House Speaker Tim Jones to be involved in the state Legislature’s upcoming decision about Medicaid. The Senate had a committee and the House had two committees to explore opportunities to transform Medicaid. Under the Affordable Care Act, states have the option of development of an exchange or obtain waivers to allow unique solutions for their state. Missouri is among a few states that have not made a decision about Medicaid expansion.
In 2012, Missouri residents voted on “whether or not the governor would be allowed to create the (Medicaid) exchange, and Missouri voters said no. The legislators will do it,” said Nurse Practitioner Kathleen Haycraft, DNP, FNP/PNP-BC, DCNP, of Hannibal. “On a positive note, Missouri is looking at transforming Medicaid and not just whether to expand it,” Haycraft said. Haycraft is the Missouri Representative of the American Academy of Nurse Practitioners and Chair of Advance Practice Registered Nurses of Missouri Nurses Association.
Haycraft was appointed a member of the House Citizens Committee to Transform Medicaid. “Our committee has the benefit of legislators, citizens, and health care professionals from a variety of backgrounds – hospital CEOs, insurance executives, pharmacists, physicians and nurse practitioners, and one recipient of Medicaid,” she said. “They have made every effort to design this committee with a breadth of experience. Rep. Torpey (R) from Independence is the chairman and Rep. Hampton (R) from Kennett is the co-chairman. They have provided stellar leadership and have held focused meetings.
“Missouri is significantly above the federal mandated income level for children and meets the federally mandated level for pregnant women,” Haycraft continued. “Missouri has challenges for working adults who are unable to get insurance.” Rep. Jay Barnes (R) introduced a bill last legislative season that would have allowed Medicaid eligibility up to the 138 percent federal poverty level. The bill did not make it out of the House. “The decision was to explore options this summer,” Haycraft said. “The deadline to create exchanges is Jan. 1, 2014. It is unsure what will actually transpire if the state fails to meet this deadline.”
Haycraft reported many people testified, and the testimony was overwhelmingly in favor of Medicaid expansion. She said that “Many distressing cases were reviewed in which patients who had worked their entire life were suddenly faced with life altering situations and were dropped by their insurance companies or their premiums exceeded their ability to pay them. When a health crisis strikes it is very difficult to continue working and thus difficult to continue to pay your health insurance premiums as well as the additional costs of being ill.” At the committee meetings, Haycraft said, “some of our business people came to testify. Small business owners have real concerns about the Affordable Care Act and how it will affect them.”
Page 2 of 5 - Many testified that if Missouri does not change Medicaid, it will have a devastating effect on hospitals “that take care of the urban poor,” she said. “Most of the people this would affect are working poor, 85 percent, working people who cannot afford the insurance.” One example she gave was Truman Hospital in Kansas City, “which projects their ‘no pay’ at 30 percent. They project they will be closing (with no changes). A lot of small hospitals can’t survive with the changes with Affordable Care Act. When you have a lot of charity cases, you get more money back from the federal government”
ACA could endanger
Under the Affordable Care Act, a hospital’s Medicaid Disproportionate Share Hospital (DSH) payment will be reduced by 50 percent, Haycraft said. If Missouri chooses not to accept the expansion or do the exchange, “all hospitals in Missouri will receive half of their DSH payments.” Many small rural and critical access hospitals stated the changes in the Affordable Care Act with its changes in reimbursement would force them to close without Medicaid expansion.
Haycraft found one of the most compelling testimonies to be the simplest. It was from a hospital pharmacist who worked in Kennett Missouri Hospital but lived in Dyersburg, Tenn. He stated, “You all go ahead and turn that money down; we will use it here in Tennessee.”
As a nurse practitioner, Haycraft was particularly interested in Dr. Patti Sohn’s testimony that referenced the Lewin report entitled: “Bending the Health Care Cost Curve in Missouri.” She stated this report indicates Missouri could save $1.6 billion in the next ten years simply by changing Missouri’s restrictive regulations on nurse practitioners. Dr. Heidi Miller works as a physician in a patient centered model and reflected that all on the team need to practice “at the top of their license.”
Other interesting testimonies addressed the dire state of the mentally ill in Missouri, Haycraft said. One committee member was an insurance agent whose son was diagnosed with bipolar disease. His son was unable to get health insurance and despite the fact that he was on probation, he chose to steal a DVD to become imprisoned and receive treatment for his bipolar disease. There were many success stories of patient centered coordinated mental health care that resulted in individuals leading productive lives after treatment, Haycraft added. Police officers testified that they drive across the state to find a hospital bed for a patient with acute mental illness. “This interferes with their duties as police officers. Many hospitals have stopped providing psychiatric inpatient care due to its poor reimbursement rate.” Much testimony was given regarding the mentally ill and lack of access resulting in the local, state, and federal prison systems becoming the primary mental health provider of mental health services. The three largest psychiatric services are actually three prisons in the United States.
Page 3 of 5 - Much discussion centered on the need to expand insurance opportunities (state or private) for the working poor, Haycraft said. Many individuals who testified had two and three jobs and due to pre-existing health conditions are uninsurable (the cost exceeded their income). The cost of meeting healthcare regulations was reviewed and a CEO of a large charity hospital stated that it represents nearly one third of his expenses. This was an ongoing statement by many institutional and individual providers of health care.
Missouri Health Net operates Missouri Medicaid. It was of interest that the state-operated Medicaid program operates on an overhead budget of less than 3 percent, whereas the managed care (operated by insurance companies) has overheads in excess of 10 percent. There is minimal savings (approximately 2 to 3 percent) with the managed Medicaid but discussion ensued over whether this resulted in reduced services to clients.
The driving forces for change are many consumer groups, individual hospitals and the Missouri Hospital Association, professional health organizations, most chambers of commerce of local communities, Haycraft said. Gov. Jay Nixon is in favor of expanding Medicaid. The restraining forces are predominately the cost and whether the federal government will be able to meet the agreed upon match.
Transformation ideas have been evaluated and include the cost of the “churn factor (individuals who have to go on and off the system), innovative case management ideas that intervene early and prevent complications (expensive), patient centered medical homes, creating a more comprehensive primary care system that would allow for care in less expensive environments (home, clinic, residential facility) and thus avoiding the more expensive emergency room care. One of the most innovative models delivers coordinated care to the super utilizer (program at Barnes Hospital presented by Dr. Randy Jotte, emergency room physician Barnes), Haycraft noted. “The super utilizers are those that represent a small portion of the population, less than 1 percent, but account for 30 percent of the costs through over utilization of expensive tests and in expensive environments.”
States to receive
90 percent Medicaid
payments under ACA
Under the Affordable Care Act, “the federal government will pay 90 percent (match) through 2015” of the Medicaid allocations. It is difficult to look at these dollars and not be tempted, Haycraft reported, adding “I am also aware of the nation’s debt, and it will be paid by our grandchildren.”
However, “If we don’t accept the (Medicaid) program, we still pay for the program,” she said. “Through taxes you would be paying for it. The hospitals and other providers of care will be paying for it through disproportional share payment reductions, and ongoing Medicare (MAC) and Medicare Recovery Audits (RAC). We will bear many of these costs whether Missouri expands Medicaid or not.
Page 4 of 5 - “The Missouri House will evaluate the situation carefully, and I anticipate that they will present a bill that will expand Medicaid for Missouri’s working poor. I suspect that when it hits the Senate that Sen. (physician) Rob Schaff will filibuster the bill. I do not believe there is the political muster for a previous question to overcome the filibuster, but, we will see,” Haycraft says. “This senator is well known for his filibusters and was responsible for Missouri being the only state in the union without a prescription drug monitoring program. This allows for increased drug abuse in Missouri.
“During the CTM committee meetings,” Haycraft added, “we have had so many physicians testify in favor of it (changing Medicaid). They see the patients’ needs. We have not had any physicians come and testify and say they are opposed.” However, the physician legislators in Jefferson City have all been opposed to any form of Medicaid expansion.
“You hear a lot of stories (people’s lives),” she said. ”It has been a good learning experience. I suppose one needs to decide who is actually responsible for the cost of an individual’s health care. Is it the government, the individual, or the employer? From a philosophical perspective, I suppose the employer makes the least sense. The issue of payment has become a complex one, as health care is the leading cause of bankruptcy in the United States. Much of the stories we heard reflected a need for reform of the insurance industry and the reform of how we think about health.”
Haycraft will be submitting her take on the committee hearings within the next two weeks to Chairman Torpey. Haycraft added that “whatever the legislature decides, I have the utmost confidence they will do the right thing in the end.”
Haycraft has invited the public to contact her by email at email@example.com or more importantly to discuss the issue with their legislators.
CEO says Hannibal
Todd Ahrens, president and chief executive officer of the Hannibal Regional Healthcare System, reported, “the financial impact of Medicaid expansion is important to Hannibal Regional Healthcare System, especially in light of the reductions in reimbursement we are facing as a result of the implementation of the Affordable Care Act and sequestration.
“However, as a nonprofit corporation, a critical issue we face in Northeast Missouri is the growing number of patients we serve who do not have health insurance or the means to pay for the care they do receive. Those individuals are unable to access primary care, instead simply having their emergent medical issues treated in the emergency room.
Page 5 of 5 - “Our mission that ‘Your Health is Our Mission’ necessitates that we find some way for all our citizens to access primary care, and doing that without the expansion of Medicaid seems unlikely. Therefore, the impact of a failure to expand Medicaid is also important to Hannibal Regional Healthcare System because this is a social issue that impacts the citizens of our region and we hope reasonable minds can find a way to set aside their differences to resolve this dilemma.”