The Faith Imperative for Medicaid
Expansion in Missouri
by The Reverend Marc D. Smith, Ph.D.
[Note from Burr:
A member of the church I attend forwarded to me an excellent paper by Reverend Dr. Marc D. Smith about Medicaid Expansion. Reverend Smith is vicar of The Episcopal Church of the Ascension in Northwoods, Missouri. He is the retired president and chief executive officer of the Missouri Hospital Association.
The paper is an examination of the Medicaid program, and its prospective expansion, from a theological perspective. It is a non-partisan document that appeals directly to people of faith. But it strikes me applying to the humanity in each of us, regardless of personal belief or ideology. It is addressed to a more universal impulse, apart from any place on the conservative to liberal spectrum.]
The Patient Protection and Affordable Care Act (ACA), popularly known as “Obamacare,” was signed into law in 2010 and argued before the Supreme Court in 2012. By a narrow margin, the justices upheld the central elements of the Act, including the controversial provision requiring individuals to secure health insurance coverage – the “individual mandate.”
As a comprehensive attempt to significantly reduce the number of uninsured Americans, the ACA included several other mechanisms, most notably requiring the states to extend Medicaid coverage to nonelderly citizens who earn 138 percent of the Federal Poverty Level or less. Substantial federal financial support for such expanded coverage, as well as a penalty, accompanied this mandate. However, the Supreme Court concluded that this provision of the ACA was unconstitutional, stating that the federal government could only withhold Medicaid funds directly linked to the ACA expansion from states who refused to comply with this requirement. Thus, each state will be allowed to determine whether its Medicaid program will take advantage of federal financial incentives to extend coverage to the poorest and most vulnerable among us without fear of penalty.
Shortly after the Supreme Court’s ruling last summer, the debate in Missouri began and will continue in the 2013 session of the General Assembly. Governor Nixon, as well as prominent nonpartisan health care, religious, community and business advocacy groups, have endorsed Medicaid expansion. When the session began earlier this month, legislative leaders appeared to be divided along political lines.
Despite successful efforts over the past two decades to increase the number of Missourians covered by Medicaid, 805,000 remain uninsured. There is little question that the overwhelming majority of these individuals are poor and at significant risk for serious medical problems. Nor can there be any reasonable debate that failure to insure these individuals has profoundly negative consequences for them, their families, health care providers and the state’s economy. As the General Assembly debates the issue of Medicaid expansion, it is critical that Missouri’s faith communities give voice to the needs of those so often ignored and take up this cause on their behalf. They deserve our advocacy, and our faith demands it.
Medicaid: An Essential Safety Net
The Medicaid program was authorized in the Social Security Amendments of 1965, creating a federal partnership with the states to assist them in providing medical services for low-income families and others who are “categorically” eligible, including the elderly, disabled, blind and pregnant women. Within federal guidelines, states are allowed to design and manage their own programs, as well as to receive federal funds to augment the financing of the care provided through them. Absent the Medicaid program, more than 60 million Americans annually would not receive essential medical care. If they did, they would likely seek it from already over-burdened and high-cost hospital emergency departments or hope to qualify for the limited resources of private charitable organizations.
The Medicaid Population
Since its inception, Medicaid has been the subject of frequent debate and strongly held opinions, unfortunately too often based on flawed assumptions. For example, many believe that access to medical care is primarily a problem of poor people of color who reside in urban areas and are unemployed. Quite the opposite is actually true. In Missouri (and nationally), Medicaid recipients are overwhelmingly white, live in rural parts of the state and work at jobs that either do not provide health insurance or do so at an unaffordable price. For example, 28 percent of the population in the Bootheel and 21 percent of the residents of the counties surrounding Hannibal receive Medicaid, compared to a substantially smaller percentage of metropolitan St. Louis and Kansas City area residents. Furthermore, and despite the almost universal coverage provided by Medicare for the elderly, nine percent of Missouri’s Medicaid recipients are over the age of 65. Contrary to popular opinion, Medicaid recipients are not on the fringes of society but are often our friends, neighbors and family members. In fact, one of every seven Missouri residents receives Medicaid.
Funding Medicaid
As with assumptions regarding Medicaid recipients themselves, beliefs regarding the funding of the program also are often mistaken. Although the states and federal government share in financing Medicaid, significant flexibility is exercised in actual practice. In Missouri, for example, hospital leaders became increasingly concerned in the late 1980s that state government was not adequately caring for the medical needs of the poor or securing the most federal assistance that was available. In response, they instituted a system of voluntary contributions paid by some hospitals which, through a provision of federal law, allowed these funds to be combined with the state’s annual appropriation of general revenues and matched by federal funds. In 1992, this “voluntary effort” was expanded to include all Missouri hospitals and incorporated into state law as a “provider tax” with the full support of then-Governor Ashcroft. It has been reauthorized as the Federal Reimbursement Allowance (FRA) with strong bi-partisan support during the tenure of every subsequent administration. More recently, Missouri’s nursing homes and pharmacies worked with the state to develop similar, but smaller, provider taxes. Today, the FRA is the third largest source of revenue for state government, exceeded only by the individual income and sales taxes.
The importance of this first-of-its-kind innovation cannot be overstated. Prior to its inception, Missouri ranked in the bottom five among the states in our medical care for the poor. However, before the substantial cuts in the Medicaid program enacted by the General Assembly in 2005, Missouri’s care for this population had improved to one of the top 10. Equally significant, this was accomplished while reducing the percentage of the state’s general revenue dedicated to the program: from 58 percent in 1990 to 18 percent in 2012. This year, Missouri will spend $3.5 billion on our Medicaid program (known as MO HealthNet), $2.0 billion of which will be funded by the FRA and other provider taxes and related transactions. Thus, any assertion that the growth of Missouri’s Medicaid program was accomplished “on the backs of taxpayers” is simply false. Indeed, while the number of Medicaid recipients almost tripled in the past several decades, the cost was largely paid for by our state’s hospitals in partnership with other institutional health care providers.
Proposed Medicaid Expansion
The “individual mandate” included in the ACA requires that those who are financially able purchase health insurance, either through their employer or privately, under penalty of a small fine. To foster a more price-competitive market, the states are expected to establish “health care exchanges” in which insurance companies will design benefit packages consistent with federal guidelines and bid for the business of employers and individual purchasers. The federal government will manage exchanges for states that elect not to establish their own. For individuals unable to afford the health insurance offered through the private market health care exchanges and available federal subsidies, the law provides financial incentives to the states to expand their Medicaid programs to include individuals whose incomes are not more than 138 percent of the Federal Poverty Level (FPL), approximately $15,800. Currently, Missouri only covers parents in families with household incomes up to 18 percent of FPL or $3,515 for a family of three. Childless adults who are not pregnant, elderly or disabled are not covered at all. To assist in subsidizing this expansion, estimated to be 307,000 people in Missouri by 2021 (including, for the first time, single adult males), the federal government has pledged to cover 100 percent of the additional cost through 2016, declining to 90 percent in 2020. Because of the unique financial leverage of the provider taxes on hospitals and other health care entities, the state’s general revenues (“taxpayers”) will actually pay less than 34 percent of the projected total cost of Medicaid expansion from 2014 to 2021.
Impact of Medicaid Expansion
Intuitively and experientially, each of us knows the value of health insurance as the vehicle for securing the medical services we and our families need. Absent insurance, many of us would forgo all but the most essential care, and most of us would be financially devastated by the cost of treating a chronic illness or the need for major surgery or end-of-life care. With health insurance, we have a reasonable expectation for a relatively healthy life, the capacity to pursue productive work and the length of our years. These also are true for the poor, and Medicaid is the national insurance mechanism designed to promote the same healthy outcomes for them.
Research on the impact of insurance on the health of economically challenged populations has been conducted for decades, and the results are unambiguous. Those without insurance, including Medicaid, are less healthy, sick more often, do poorer academically, miss more days of work, are more costly to treat and live fewer years. The personal, family and societal costs are as painful and heartbreaking as they are avoidable. Nationwide, for example, almost 20,000 people die each year for no other reason than the lack of the health insurance necessary to receive care.
Not only can Medicaid expansion in Missouri be expected to decrease preventable deaths and increase the health and productivity of the most vulnerable among us, it also will significantly reduce the hundreds of millions of dollars hospitals, physicians and other health care providers annually pass on to insurance companies, employers and individuals to subsidize the medical care of those unable to afford insurance. And in a recent study completed by researchers at the University of Missouri, the expansion of the Medicaid program is conservatively projected to generate 24,000 new jobs and $7 billion in payroll during the next 8 years, which together will add almost $10 billion to our state’s economy.
The Faith Imperative for Medicaid Expansion
Compelling economic, health status and social justice arguments can be made in support of Medicaid expansion in Missouri. It will save money, grow the economy and improve the health and wellbeing of those most at risk for avoidable illness, premature disability and death. In addition, it will provide a solid platform for enhancing service delivery and the engagement of Medicaid recipients in the management of their care. Simply stated, it’s the right thing to do as a compassionate society.
Even more important, the faith we profess and the community to which we are bound as the Body of Christ, the church, demand our advocacy on behalf of the most vulnerable among us. The Biblical witness – beginning with the Deuteronomic Code, given passionate voice in the Psalms and uncompromisingly applied to the life of Ancient Israel by the prophets – establishes the care of the poor (as well as widows and orphans) as fundamental to the covenantal life of God’s people. Broadly encompassed in the Old Testament concept of “justice,” the Hebrew Scriptures make clear that these responsibilities are to be extended in equal measure to strangers and guests, as well as to those within the faithful community. To do so is deemed to be “righteous.” However, perhaps most significant for our understanding of the imperative to bear witness and respond to the needs of the oppressed is that Ancient Israel gradually came to recognize that righteousness not only attached to those whose actions reflected their covenantal relationship with God, but also to the oppressed themselves whom God accepted as righteous specifically because of their oppression. This will have profound implications for the evolution of the New Testament expression of justice and the demands of our faith for pursuing it in society.
The Gospel narratives are replete with Jesus’ embrace of socially marginalized and ostracized “others” – lepers, tax collectors and adulterers. To be sure, his actions reflect the righteousness of the faith he had inherited, but this exemplary life is neither the full story nor the basis of our faith and the communal life we share as his disciples. As God incarnate, God in human flesh, Jesus assumed the breadth of the human condition, most strikingly himself becoming poor, a servant and a victim. Not surprisingly, therefore, Jesus asserted in response to questions regarding the care offered to those who were hungry, thirsty, naked, sick, in prison or strangers: “just as you did it to one of the least of these who are members of my family, you did it to me” (Matthew 25:40). In all who need our care, we are to see Jesus and in serving them, we embrace him.
Clearly, then, there is an expectation that we as the Eucharistic community – all who share in the Body and Blood of Christ – will respond with grace and generosity to the needs of society’s most vulnerable. However, the witness of Jesus’ life, death and resurrection actually compels an even more assertive faith, a faith that not only responds to but actively seeks out and identifies with them. As Jesus so often demonstrated, we are to have a “preference for the poor.” Quoting Isaiah, for example, he announced that, “The Spirit of the Lord is upon me, because he has anointed me to bring good news to the poor. He has sent me to proclaim release to the captives and recovery of sight to the blind, to let the oppressed go free, to proclaim the year of the Lord’s favor” (Luke 4:18-19).
That faith in Christ and the life of the church are to be expansive, as well as proactive, also are captured in The Baptismal Covenant, in which we commit to, “… seek and serve Christ in all persons, loving [our] neighbor as [our]selves” and “… strive for justice and peace among all people, and respect the dignity of every human being” (Book of Common Prayer, p. 305). Thus, the care of “the least of these” is not optional nor to be left to chance encounters. Rather, in all its many and varied manifestations in contemporary society, it is to be actively pursued, engaged and demanded.
Call to Faith in Action
The health of the most vulnerable Missourians among us is just such a manifestation. Full access to the essential health care services they need and deserve can only be accomplished through public funding of health insurance for them. And, the expansion of our state’s Medicaid program is the most available, responsible and economical vehicle for accomplishing this critically important objective.
The debate over Medicaid expansion in the Missouri General Assembly will likely continue throughout the legislative session, which ends on May 17. There will be much we can do in the months ahead to advance this effort. Most important, however, is to share our support with our legislators by contacting them by email at www.missourihealthmatters.com. Together, let us join in common cause with those whose very lives depend on our faithful and tireless advocacy. “Just as you did it to one of the least of these who are members of my family, you did it to me.”
The Reverend Dr. Marc D. Smith is vicar of The Episcopal Church of the Ascension in Northwoods, Missouri and retired president and chief executive officer (1998 – 2010) of the Missouri Hospital Association. He can be contacted at cotterboatworks@aol.com or (314) 452-3378.
Original post blogged on b2evolution.