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Debate over Medicaid expansion is as hot as gun control in parts of south Missouri

In Health

4:11 am on Wed, 04.10.13

While  enjoying a plate of gravy and biscuits at Feller’s Family Restaurant last Friday morning in Willow Springs, Mo., Johnny Morgan energized the breakfast conversation with examples of what he regards as unwarranted government intrusion into people’s lives.

Pushing back his camouflage cap, he brought up gun control and explained that the issue should only mean “use both hands” and not a ban on certain weapons. Colleagues seated around his table didn’t miss a beat, joining him in a burst of laughter.

Johnny Jones, Steve Foster and Johnny Morgan at Feller's Family Restaurant, Willow Springs, Mo.
Robert Joiner | for the Beacon
John Jones, Steve Foster and Johnny Morgan at Feller's Family Restaurant, Willow Springs, Mo.

His tone had grown somber by the time he got around to another hot topic, Medicaid expansion, which he and many others derided as Obamacare. They said it means more government control and that Missouri would be better off rejecting Washington’s start-up money for it.

Cattleman Steve Foster, tall with white hair and a matching beard, chimed in: “There are a lot of things we’d like to do for people, but we just don’t have the wherewithal to do it. We need to get the government out of our lives because they’ve never fixed anything.”

At another table sat Shirley Minnich and her husband, Robert.  After warning that “the government will start a civil war if it tries to take away our guns,” she picked up the Medicaid expansion topic, saying, “I don’t think people can afford it anymore. We’re taxed to death. Another tax is going to mean less jobs. We need to find a way to put people to work and not have them depend on Medicaid.”

Not everyone in Howell County or south central Missouri buys those arguments about Medicaid. Many say the money to expand Missouri’s system would give the needy more access to safety-net providers, the largest being Ozarks Medical Center, the only Missouri hospital within a 100-mile radius.

At the moment, however, sentiments like those heard at the restaurant seem to be winning in Jefferson City. Senate leaders have now told Gov. Jay Nixon that Medicaid expansion won’t survive this legislative session. Aside from philosophical reasons,  the lawmakers argue that the federal budget already is written in red ink and can’t afford to spend billions more to expand Medicaid.

It’s a conclusion that doesn’t sit well with many medical and business leaders who say that the federal and state cost of expansion is projected to be offset by more than enough jobs and tax revenue to justify the investment. These leaders add that expansion would be especially good for rural parts of the state where the local hospital is by far the largest employer.

That’s true of Ozarks Medical Center, based in West Plains, the region’s top economic engine. It is the source of 1,315 jobs with an annual payroll of $61.2 million from 114 hospital beds, a state-of-the-art emergency department, and 19 rural and specialty clinics, some of which reach into remote areas where health care otherwise would be less accessible.

The worry now is how strong the hospital’s safety net will be in future years in the event those opposing Medicaid expansion prevail. Starting this month, the medical center is losing 2 percent of its federal payments, or more than $600,000, because of sequestration, the automatic cuts growing out of earlier federal budget negotiations. Starting in October, when the Affordable Care Act takes full effect, the center will be among those Missouri hospitals that will begin to lose $4.4 million in disproportionate share payments during the next seven years.

David Zechman, CEO, Ozarks Medical Center, Willow Springs, Mo.
photo provided
David Zechman, CEO, Ozarks Medical Center, West Plains, Mo.

David Zechman, CEO of the Ozarks Medical Center, said the assumption had been that Missouri would offset cuts under ACA by expanding Medicaid, with the federal government picking up the full cost of expansion during the first three years, starting next January, and states ultimately picking up 10 percent of the tab.

A failure to expand Medicaid could eventually affect the amount of charity care the hospital provides. The amount jumped from $6.5 million in 2010 to $10.1 million last year, driven partly by economic conditions in the region. Some health facilities serving rural communities, including Pemiscot County Memorial Hospital in Hayti in southeast Missouri, have warned that a failure to expand Medicaid could eventually cause them to go out of business.

For now, Zechman foresees more belt-tightening and no cuts in hospital services. “But that doesn’t mean we won’t have to consider that in the future.”

Expansion of Medicaid would allow Ozarks Medical Center to reach even further into medically underserved pockets of the region, adding more than 4,000 people in Howell County alone, where the 21 percent of residents lacking health insurance is among the highest in the state.

Missouri’s Medicaid system is limited mainly to children, the elderly in nursing homes and the completely disabled. If expanded, Missouri Medicaid would cover individuals and families earning up to 138 percent of the federal poverty level, meaning a four-member family earning up to $32,000 a year would qualify.

Maggie Beedles and her husband, Chris Feaster, would be grateful.  He earns $400 a week as a chef, while she is a housewife who home-schools the couple’s three children – Amadeus, 6; Gaea, 5; and Nike, 2. The couple pays $300 a month rent for a house nestled in a wooded area at the end of a one-lane rub board of a dirt road off Highway F. Last Thursday afternoon, Beedles talked about the family’s plight as she collected the family’s wash from a clothes line while her children romped noisly on a trampoline in the yard.

Maggie Beedles and her three children
Robert Joiner | for the Beacon
Maggie Beedles and her three children

Originally from Kansas City, Kan., the couple settled in Howell County because they said the cost of living was lower, and they enjoyed a rural back-to-nature lifestyle, where they can grow food and heat their home with wood.

“I had state health insurance when I was pregnant,” she says. “But now in my 30s, I’ve never had a well-woman’s physical, haven’t had a pap smear or a mammogram in many years. We live from paycheck to paycheck, so expanding Medicaid would be good because it would allow me to see a doctor on a regular basis and do more preventive medicine.”

State Rep. Shawn Rhoads, R-West Plains, acknowledges the large number of uninsured residents in his district, and he thinks expansion might occur at some point after Missouri figures out a way to put people in charge of their health care. He also acknowledges the importance of Ozarks Medical Center to the region’s economy and its medical care system. He has “no problem with expanding Medicaid,” but his big concern is that the “federal government wants to spend billions of dollars in new money that it doesn’t have.  That’s the scary part.”

That’s part of the talk of the town, says Wendell Bailey, a Willow Springs Republican who was former state treasurer and former congressman who lost his 8th congressional district seat after redistricting based on the 1980 census.

Wendell Bailey
photo courtesy of West Plains Daily Quill
Wendell Bailey

Bailey says residents of south central Missouri “don’t want to be bossed around by government. They don’t like it. The damned government. That’s what they say. When Gov. Nixon came down here and said the federal government is going to bring us some money, the people wanted to know what government. What money? We don’t have any money. Does the government have some money that we don’t know about? They are saying it is a fraud.”

Bailey, in his 70s, sounds like a recovering politician, acknowledging he’s still trying to get a love of politics out of his system. In the meantime, he works to shore up Willow Springs’ economy, being part of a movement to lure a college branch campus to empty highway department buildings that have been vacant since the highway program and its more than 100 jobs were transferred to Sikeston. He has also helped to find funds to refurbish and convert an old two-story downtown department store into an educational center with computer work stations on the first floor and space for violin lessons and a chamber orchestra and string quartet upstairs.

Among those still trying to make sense of the Medicaid debate is Arlene Anderson Arnold, who runs a downtown Willow Springs portrait business that has captured weddings, proms, baby showers and other milestones over the years.

Arlene Anderson Arnold
Robert Joiner | for the Beacon
Arlene Anderson Arnold

She says, “I’m not particularly comfortable with the label ‘Obamacare.’ Generally when I hear people use the term, it has negative connotations. I don’t know what they mean or what services they think they are going to get or services they are not going to get.”

What’s missing in the debate, she says is solid information to help people understand Medicaid. “I think Medicaid is very helpful for the people who need it. The deficit is another complicated thing, but I think public funds for health care for people who can’t afford it is really needed.”

What happens to the Medicaid expansion issue has implications not only for the main hospital, but for other parts of the safety net, including the Martha Vance Samaritan Outreach Center.

The smell of frying pork chops and baking yams floats through the air from the kitchen of the center where resident Charlie Moore, 44, is preparing dinner for the 28 people, including five children, who live in the shelter.

“Fifty percent of the people I have up here right now don’t have health insurance,” Rosie Perez, director or the outreach center, says.  “If somebody needs Medicaid, they should be able to get it and use it until they can get back on their feet, get insurance or some kind of income. That’s why it’s important to expand the program.”

A similar thought ran through the mind of Lisa Murdy, a 45-year-old mother of two, a woman twice victimized by stroke. She doesn’t work and her husband, who is employed by a car dealership, supplements the family income as a string musician.

“I just wish there was more help for people who don’t have insurance and aren’t able to take care of themselves,” Murdy said as she waited for the Willow Springs food bank, Missourians United to Combat Hunger,  to open around noon Friday.

Not far away stood the Rev. Sherman Wall, the priest at Sacred Heart Catholic Church. “I’m not altogether convinced that everybody needs health insurance,” he said. “I know the theory that everybody should be paying into a health-care fund for everybody, but I am not convinced that this is needed. People can do what they do now. They go to the hospital emergency room. They go to the clinic. They may not get the latest state-of-the-art health care, but they get pretty close to that.”

Emergency department at Ozarks Medical Center, Willow Springs, Mo.
photo provided
Emergency department at Ozarks Medical Center, West Plains, Mo.

Relying on the hospital emergency room for care might not be an option if Medicaid isn’t expanded and health-care cuts under the Affordable Care Act leave hospitals with fewer resources, including clinics and emergency room space, to care for the needy.

Critics seem to have a ready explanation for potentially longer waits in hospital emergency rooms, fewer services or, worse, a shutdown of some hospitals. These things might happen, they say, because “Obamacare” is ruining rural health care.

In the meantime, residents like Johnny Morgan, who opposes Medicaid expansion and others like Charlie Moore, who want to see it happen, can only sit and wait to see what the legislators in Jefferson City will do.

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