Ask Victoria Altic about her health and she'll respond with a credit report.
Whenever Altic has seen a doctor in recent years, whether for a ruptured eardrum or epilepsy, it’s usually meant another bill she can’t pay added to a ledger already full of them.
She says she's worked a number of jobs to pay them off, but it’s not easy with rent, two kids and high interest rates.
That was before the novel coronavirus threw a wrench in her work prospects and caused her to her worry about what she would do if she caught it.
With no insurance, going back to her last job at a restaurant would mean risking illness, then debt, then the parade of collector calls, court hearings and wage garnishment.
“These things are happening to us that are out of our control,” Altic said, “and they put you on a path where there’s no way out of it.”
For years, a broad coalition of advocates, policy wonks and industry leaders have said there’s another path, though: Medicaid expansion.
On Aug. 4, those groups are asking Missouri voters to vote "yes" on Amendment 2 and offer state coverage to Altic and other Missourians living a little above or anywhere below the federal poverty line.
In this story and others following this week, the News-Leader will examine what that change would mean for residents, the providers who would treat them, and the taxpayers covering most of the cost.
Today, the focus is on the expansion population, who, research suggests, would have better access to care, see their financial health improve, and in some cases, add years to their lifespans.
Access to care
Tim Shryack knows the predicament well.
Missouri Ozarks Community Health, where he’s the CEO, tries to keep services at clinics in Douglas, Wright, Texas and Ozark counties as affordable as possible: a full dental exam with extracted teeth can be as little as $50.
“But sometimes $50 to you and me might as well be $500 to somebody else,” he said.
That’s when people are faced with two bad choices: go without care and let their problem fester, or take it to the emergency room, where things get really expensive.
Medicaid recipients don’t have that problem, and supporters say Amendment 2 would allow many more people to avoid such choices.
In a review of studies published over a six-year period, researchers at the Kaiser Family Foundation found dozens of analyses showing expansion leads to higher Medicaid enrollment across virtually all major demographics.
Missouri, with some of the toughest eligibility levels in the country right now, appears primed for the same. Currently, parents who are not pregnant, and people who are disabled and elderly are cut off at 21 percent of the poverty line. Childless adults can’t be covered at all.
Expansion would allow coverage up to 138 percent of the federal poverty line — $17,600 per year for an individual or about $36,150 for a family of four.
Once the expansion population is enrolled, which would happen starting next summer under Missouri’s proposal, research suggests they’ll seek more care than they did previously and make fewer bad calls.
A 2017 Harvard study comparing three years of data from expansion states Kentucky and Arkansas and non-expansion Texas, for example, found patients in the first two states got significantly more preventative care than Texans.
They were more likely to have a personal doctor, get a yearly checkup and get screened for diabetes and high cholesterol. They were also less likely to go to the emergency room or delay treatment due to cost concerns.
To be sure, not every study on expansion has found a decline in ER visits. But other studies have suggested that at the least, expansion states are seeing fewer patients using the ER as primary care and more people using the ER for genuine emergencies.
Dr. Jim Blaine said that’s exactly how it should be.
In 17 years in local ERs, he saw countless patients who could have avoided the visit if they had gotten some preventive care.
Even serious situations, like heart attacks, were often the result of smoking or high blood pressure that could have been treated before they boiled over, and the more minor issues — infections, sprained ankles and cuts — were often people with nowhere else to go.
He counted Victoria Altic’s ruptured eardrum as another example.
Before she went the the ER and then a specialist, racking up bills along the way, she just had an ear infection.
Blaine said if one of his regular patients had that problem, they could text him, come in the next day, get a prescription for antibiotics and move on.
“Saves you money, saves the system time,” he said.
Research indicates Blaine is correct.
Tim McBride, a health care economist at Washington University in St. Louis, said the first thing researchers see after a state expands Medicaid is a drop in out-of-pocket costs.
From there, a number of other things happen.
Researchers at the federal Consumer Protection Financial Bureau reviewing 5 million credit records found expansion significantly reduced how often people took on new medical debt.
On average, they found an annual impact of $37 per person, or $900 per treated person, which kept $3.4 billion in bills out of collections in the first two years of expansion.
The cost-savings may not stop with fewer medical bills.
Candidate surveys: House District 134 candidates discuss Medicaid expansion, more
The same study also found people in expansion states saw improvements in credit score and paid less in interest on loans and credit cards, adding up to $12 per person and $280 per treated person per year. The researchers also linked expansion to 50,000 fewer bankruptcies among high-risk borrowers in the first two years of expansion.
Multiple studies have also suggested a link between expansion and a reduction in evictions.
One published in Health Affairs last year examining data from California found early expansion there was associated with 22 fewer evictions per year for every 1,000 new enrollees.
Altic hasn’t filed for bankruptcy, but she’s been close to eviction more than once.
A trip to the ER for seizures at one point was so expensive she wasn’t sure how she could pay for it without putting her family on the street.
“We would be homeless,” she said. “We would be without utilities. And I’m trying to figure out what to do, like, how?”
McBride, the Washington University economist, said the cost savings can also improve a person’s mental health.
Reannon Stark, a 20-year-old in Webb City, can believe that.
At one point, the stress of debt compounded her existing anxiety to the point that she attempted suicide.
A trip to the hospital saved her, before sending her home with a $2,000 bill.
“I left the hospital and got another letter for the exact same reason I was stressed out,” she said.
She was able to get follow-up help at a low-cost clinic while living with her mom.
Eventually, though, she had to get a job and move out, and even minimum wage at Taco Bell pushed her up the clinic’s sliding scale enough to make further appointments too expensive.
“It was like I’m supposed to not eat to go to therapy,” Stark said.
Expansion, she said, would let her take care of herself.
“It would take a weight off my shoulders,” she added. “I could finally get an actual check-up.”
Along with lifting financial burdens and offering better access to care, expansion may also add years back to some people’s lives.
Perhaps the most dramatic research in recent years came in a 2019 working paper published by the National Bureau of Economic Research. It estimated expansion prevented 19,200 disease-related deaths in expansion states in its first four years, a benefit researchers predicted would continue to grow.
Researchers also estimated that non-expansion states had 15,600 more deaths than they would have had under expansion.
Another study published this year linked expansion to a 6 percent drop in total opioid overdose deaths in 32 expansion states from 2015 to 2017.
Researchers have also found more everyday gains tied to Medicaid expansion, like improvements in self-reported health for low-income childless adults nationwide in the first three years of expansion.
A survey of thousands of enrollees in Michigan published this month found those kinds of improvements sustained themselves for those who keep coverage over time, too.
Those adults also reported fewer days when poor health prevented them for taking part in their usual activities.
Shryack, the Missouri Ozarks Community Health CEO, outlined similar hopes for patients in his area under an expansion of resources.
“We feel like we see an increase in patients, and we could get people care,” he said, “and if we can get people feeling better, get control of their blood pressure or diabetes, they can keep their job because they don’t have to call in sick or quit, then get a better-paying job so they can get off Medicaid."
Shelby Smith, a primary care doctor in Springfield whose clinic is specifically geared toward treating uninsured or under-served patients, cautioned that nothing happens overnight.
When new patients come in for their first appointment with him and tell him they haven’t had insurance in years, it can take multiple appointments to assess and address all the issues.
“I tell them, ‘We didn’t get here overnight, we’re not going to change all this overnight,'” he said in an interview.
“But we do get there,” he added.
“I had a guy come in a few years ago with a ton of issues, and now I never see him anymore except when he comes in to pick up his meds.”