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Adding Dental Care Contrasts With Mo. Legislature's Opposition To Medicaid Expansion

Apr 16, 2014

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JEFFERSON CITY -- Republican opposition in the state Senate has dimmed hopes that Missouri will expand Medicaid this year to cover the working poor

But agreements are percolating on what might be called Medicaid Expansion Lite.

In the most far-reaching move, next year’s state operating budget almost certainly will restore limited dental coverage for 300,000 low-income adults whose benefits were cut in 2005. Coverage for rehabilitative therapy also might be reinstated.

There’s a chance lawmakers will let elderly and disabled people stockpile small nest eggs without losing their Medicaid coverage, a change that could add 8,174 adults to the rolls.

And liberals and conservatives alike back a bill covering more pregnant women by including “unborn children” in the state Children’s Health Insurance Program, an arm of Medicaid. An estimated 1,844 women could gain prenatal services.

Legislators pushing the piecemeal additions include Sen. Rob Schaaf, a physician and one of the staunchest opponents to the federal Affordable Care Act’s blanket Medicaid expansion. He portrays the changes as reforms that would save taxpayers money by decreasing emergency room use.

Dental care “is part of the safety net that we just completely ignored for people who are dependent on us,” Schaaf, R-St. Joseph, said last week. “This is as preventative as it gets.”

Supporters of full-blown Medicaid expansion say piecemeal changes are helpful but won’t generate the $2 billion a year in federal funds and 25,000 jobs that Missouri could gain if eligibility were broadened as envisioned by federal law.

The broader plan would cover about 300,000 Missourians making up to 138 percent of the poverty level, or $16,104 a year for an individual. The federal government would pay the full cost for two years, with the state’s share phasing up to 10 percent by 2020.

On Tuesday, Gov. Jay Nixon, a Democrat, announced a state website, www.Mo.gov/WePaidForIt, that aims to track the federal money Missouri has given up by rejecting the larger expansion. He pegs the loss at $5.47 million a day.

Nixon said in a statement Tuesday that broad expansion was more cost-effective because the state would “cover zero percent of the cost now. The General Assembly’s approach to expanding Medicaid covers fewer people, and makes the state pick up 36 percent of the cost.”

Incremental changes “are all good,” said Rep. Chris Kelly, D-Columbia, “but they all pale before expansion.”

TOOTHACHES IN THE ER

Medicaid provides free or low-cost health insurance for 828,478 low-income Missourians. About 60 percent are children. The rest are custodial parents, pregnant women, the elderly and people with disabilities.

There are varying eligibility thresholds. For example, Missouri’s income cutoff for parents — 19 percent of the poverty level — is the lowest allowed by federal law. But children are covered in families earning up to 300 percent of poverty, which is among the highest levels nationally.

In 2005, then-Gov. Matt Blunt and the Legislature eliminated an array of services, including dental care for most adults. Republicans said the cuts were needed to balance the budget and free up money for other priorities.

Since then, Medicaid has provided dental benefits only for children and for adults who are pregnant, blind or in nursing homes. That leaves out Ebonnee Estes, 28, of St. Louis. She said she had been unable to find a dentist she can afford, especially since she was laid off as a nurse’s aide in February.

“I have two teeth that are chipped, and one has developed a cavity,” she said. “I do not have dental coverage, so it’s too much money to be able to come up with.”

Because poor oral health care can lead to teeth decay and infection, people without dental insurance often wind up in emergency rooms, where services are more costly. Then the underlying problem, such as an abscessed tooth, may go untreated.

“Sometimes the emergency room will just give out a painkiller,” said Tom Farmer, a dentist from Clayton who sees Medicaid and uninsured patients at his walk-in clinic in north St. Louis.

“They won’t give out any antibiotics. Or the person will go to the emergency room multiple times. Finally they show up and the emergency room can’t help them or the infection’s so bad, they end up in the hospital.”

Those arguments persuaded the House to earmark $48.2 million in federal and state funds to restore adult dental care in the budget that takes effect July 1.

The Senate has not yet voted on the budget, but dental coverage is virtually certain to pass because last week, the Senate Appropriations Committee approved the same amount as the House did.

However, the Senate committee carved it up differently. Instead of a full package of dental benefits, the Senate would fund only 30 basic procedures, such as exams, X-rays and extractions.

By leaving out high-tech treatments, such as bone biopsies, senators reserved $17 million to raise the rates Medicaid pays dentists. They would draw 60 percent of the usual rate, up from about one-third of the norm. The Missouri Dental Association proposed the rate increase to encourage more dentists to participate in Medicaid.

POTENTIAL ADDITIONS

Dental care isn’t the only service that was slashed in 2005 but will be back on the table when House and Senate negotiators reconcile their budget differences.

The House also wants to reinstate occupational, speech and physical therapies for adults.

A licensed physical therapist, Rep. Sue Allen, R-Town and Country, said it made no sense to cover the cast and surgery for a broken wrist, for example, but not the therapy to help the injured person regain strength and range of motion.

Other additions in the House-passed budget include individually fitted wheelchairs, an asthma education program, a pilot program to coordinate care for foster children and rate increases for Medicaid providers.

Meanwhile, the program’s rolls could grow slightly under several bills that would help the elderly, people with disabilities and pregnant women.

Currently, a single elderly or disabled person on Medicaid can accumulate savings of no more than $1,000. For a married couple, the maximum is $2,000.

Set in the 1960s, the asset limits make it hard for people to stay in their homes, because they can’t afford major repairs.

“We all know, when you have a home, things go wrong all the time,” Joanie Gillam, a supervisor at the Disabled Citizens Alliance for Independence in Viburnum, told a Senate interim committee on Medicaid transformation.

The committee proposed a wide-ranging overhaul that includes doubling the asset caps. Though it has bipartisan support, it has bogged down because of some senators’ fears that the bill could be amended to include the broader expansion of Medicaid eligibility.

“The key is to make sure they understand we’re putting together a program that’s a Missouri plan,” said the sponsor, Sen. Gary Romine, R-Farmington. “A lot of folks don’t like the federal government forcing a plan down our throats.”

If a Medicaid reform bill begins moving, adding “unborn children” is among the ideas that could gain traction.

Called the Show-Me Healthy Babies program, the proposal would give women making up to three times the poverty level coverage for pregnancy-related services and two months’ postpartum care.

“There’s a lot of people who want to see that across the finish line,” said the sponsor, Rep. Jeff Grisamore, R-Lee’s Summit. Currently, pregnant women are covered at 185 percent of poverty.

The outlook for the broader Medicaid expansion envisioned by the Affordable Care Act is much less promising. Some proponents say the broader expansion could pass in the House. However, opponents — who call the expansion financially unsustainable — have signaled they would use a filibuster to block it in the Senate. For that reason, many say it’s probably dead for this year.

“It has an extremely high hill to climb,” Senate President Pro Tem Tom Dempsey, R-St. Charles, told reporters Monday.

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