Shirley Porterfield, who holds a PhD in economics, conducts research and teaches a course in health policy in her role as a professor in the School of Social Work. (Photo by August Jennewein)

The Affordable Care Act, signed into law a decade ago, expanded the list of people who could receive health care coverage under Medicaid.

It increased the eligibility requirement to those earning 133 percent of the federal poverty level, but states have had to opt in to the expansion after a Supreme Court decision in 2012 blocked the federal government from mandating they go along with the change.

There remain 14 states that have not expanded Medicaid, but on Aug. 4 voters in Missouri could shrink that number by one if they pass a Medicaid expansion initiative known as Missouri Amendment 2.

Shirley Porterfield holds a PhD in agricultural and applied economics and conducts research and teaches a course on health care policy in her role as a professor in the School of Social Work at the University of Missouri–St. Louis. In the latest installment of its Ask an Expert series, UMSL Daily talked to Porterfield to talk about the pros and cons of the ballot measure.

If you go back to when the ACA was passed, was Medicaid expansion expected to be this contentious?

I don’t think so. Of course, the assumption of the federal government was that they could mandate Medicaid expansion. On the other hand, when Medicaid came in as a program, it was signed in 1965. It began in 1967, and 26 states adopted the program in 1967, and 11 more adopted it within the first three years. But then Arizona didn’t adopt it until 1982. So I suppose there should have been some hint this would be the case. Everything is so contentious politically right now, and I think health insurance just becomes one of those contentious things.

I think there were 25 states that expanded it immediately. Gradually, more have joined that list. What have been the benefits that they’ve seen?

For one thing, I want people to realize that no state has repealed their Medicaid expansion. So nobody’s had such a bad experience with this that they thought it wasn’t worth it. In those states, there are more people insured. Those states have done fairly well economically, so none of them have seen a huge hit on their state budgets for Medicaid expansion.

We did some work a couple of years ago looking at young adults with disabilities compared to young adults without disabilities and looking at Medicaid expansion because of the dependent coverage provision which allows people to keep kids covered on their family plan up through their 26th birthday. We found that Medicaid expansion was significantly positive for both health insurance coverage and for a reduction in delays in access to care. That’s been pretty much the story in states that have expanded Medicaid.

I think adjusting to the expansion has been a little bit of a struggle administratively for states because a lot of states run very antiquated Medicaid infrastructure systems or administrative control systems. But other than that, I think it’s been a boon for states. States that have expanded Medicaid no longer have an issue with uncompensated care, for example – people who are getting health care who can’t afford to pay for it because those people aren’t covered.

What is the argument against expanding Medicaid? Why is there resistance to it?

Opponents would argue that expanding Medicaid will be too expensive because it’s estimated that between 250,000 to 350,000 people will come on to the Medicaid rolls. There is an estimate that more than 600,000 people will come on to the Medicaid rolls, but that just seems unrealistic.

Isn’t it true that the federal government would fund 90 percent of the cost for those new enrollees?

Yes, with current Medicaid enrollees, the state pays about a third or actually 35 percent, and the federal government pays about 65 percent. For the new people coming on to the rolls, 90 percent of the money will come from the federal government and 10 percent from the state.

That is money the federal government puts forward only if states expand Medicaid. How does that money get spent if Missouri does not vote to expand Medicaid?

It’s spent in other states, so all of our tax dollars that go to pay for the ACA just flow out and they don’t flow back in except to do some subsidies for people who buy marketplace insurance. But those are only people above 100 percent of the poverty line. Anybody between 19 percent and 100 percent of the poverty line, who isn’t certified as permanently and totally disabled or who isn’t a pregnant woman is just out of luck.

What is the size of the healthcare gap in Missouri in terms of number of people who are uncovered?

Right now about 613,000 people are without health insurance. That’s an increase of about 100,000 since we started in the COVID era. Those are people that lost their jobs and couldn’t move onto a spouse’s plan. That’s from a Family’s USA study that was just published a week ago.

What’s the profile of people who would benefit from Medicaid expansion?

Eighty to 85 percent of them are working. Clearly, these are people who are below 138 percent of the poverty line. For a family of four it’d be $36,156. For an individual, it’d be $17,609 in 2020. So it’s probably a lot of the essential workers that we’re seeing now.

In support of this bill is basically every healthcare organization in the state. Why have they come out in favor?

Probably partly because they’d like to get paid for all the people they treat, right?

It’s just a lot easier when people have insurance. When people don’t have insurance, you have to do some charity care, and the state claws back some money from hospitals to try to cover charity care. There’s a lot more problems administratively dealing with someone who doesn’t have health insurance and figuring out how to pay for them.

Also, people who have health insurance tend to get care in a timely manner, and people who don’t have health insurance tend to get care late. That becomes more expensive. They don’t do preventive care because it’s expensive and out of pocket often for them, so they don’t do it until it becomes problematic enough that they can’t work or can’t function in their daily life.

Is there a discrepancy in the benefits of expansion for cities compared to rural communities?

Rural communities will probably benefit more actually than urban because rural people are less likely to be insured and they also have lower incomes, so they’re more likely to fall into the coverage gap. They’re also more likely to work for small employers who don’t provide health insurance for their employees.

About one quarter of the population in Missouri lives in rural areas, but it’s estimated that about one third of those who will be covered by the expansion will be from rural areas. That’s according to analyses that have been done by the Center for Health Economics & Policy at Washington University.

How serious is the problem of rural health care in Missouri right now?

Since passage of the ACA, seven hospitals – rural hospitals – in Missouri have closed. So, there are a number of counties where there is no health care, or if there is health care, there’s no emergency care or there’s no obstetric care. I think it’s significant, not just in Missouri but across the country.

Is there a link between the ACA and those rural hospitals closing?

I don’t know that there’s a direct link, but a lot of rural hospitals that have gone under have cited the increase in uncompensated care. So, if they they’re treating people and they can’t collect reimbursement for that treatment, they’re more likely to go under. In states that didn’t expand Medicaid, there’s not a lot of money for uncompensated care. All uncompensated care was supposed to go away. Those people were all supposed to be covered under Medicaid expansion, so the rules that govern how the federal government dealt out uncompensated care funds – those all changed under the ACA, and then they got tweaked when not all states adopted Medicaid expansion.

How often do you talk about the issue of Medicaid expansion in your classes?

I teach health care policy in the fall every year. I always have a full class. I think I have 25 people currently signed up for the fall. We talk about Medicaid and Medicaid expansion maybe not every class period but a lot. We talk about how the ACA impacts different groups, how it impacts health disparities, how it impacts insurance rates, so there’s a lot of discussion about this in my class.

Has there been much research done on the healthcare outcomes in states that have adopted it?

Yes, definitely, we know that people get care sooner in the progression of their disease, and we that there has been less forgoing or delaying care because of cost. Whether people are actually healthier yet, I don’t know.

What got you interested in health care policy?

I have a son with a significant disability. So, many years ago, I shifted what I was doing to try to figure out what was going on with him.

How would Medicaid expansion affect people with disabilities?

Missouri state numbers show a little over 4,000 people with disabilities applied for Medicaid in Missouri per month in FY2017.  About half – 53 percent – met the disability criteria and were enrolled with the remainder not enrolled. Some portion of that remainder could come into Medicaid as part of the expansion group, meaning their coverage would receive the higher federal subsidy rate.

A study done at the University of Kansas looking at the first few years of the ACA found that community-living, working-age adults under age 65 were significantly more likely to be employed in Medicaid expansion states (38 percent) than in non-expansion states (31.9 percent). Basically in non-expansion states, people with disabilities have to go through the Social Security Administration’s disability determination process and they have to be poor to qualify for health insurance. Medicaid expansion allows these people the dignity of work and provides for their health care needs.

Not all people who are categorized as permanently and totally disabled are unable to work. They perhaps can’t work full time, or they have cognitive or physical limitations that prevent them from getting jobs that pay very well or that offer health benefits. Currently, the state tells them they can’t have health benefits unless they are in poverty, effectively preventing them from working at all. This is the population that most of my research has been focused on, and I feel strongly that they should be able to achieve their potentials just as those of us without disabilities are exhorted to do.

Do you expect Medicaid expansion is going to pass? Do you have any guess?

I hope so. Yeah. I’m completely for this idea. I think it’s a great idea. I don’t see any downside. I know the state is worried, but I think a lot of the reason why we haven’t passed Medicaid expansion is for political reasons, not economic reasons.

I look at the economics and look at what happened in other states, and it makes perfect sense to me. Your populace is covered. They have health insurance. Your hospitals get paid. Because your hospitals get paid, they might hire more people. You have more people going to the doctor, so doctor’s offices hire people. There is a multiplier effect that happens when everybody is covered with health insurance. I think that would benefit the state of Missouri. I don’t see a downside. I don’t see a state that’s had a downside. Will it pass? I don’t know. If you look at the polling that was done a while ago, it certainly appears that the majority of people are in favor of Medicaid expansion but will they come out of vote? I don’t know.