One of the aspects of the Affordable Care Act, also known as Obamacare, involves providing insurance policies to those who couldn't otherwise afford insurance.
But it was also meant to bring down costs for those already insured, those who won't need to buy insurance through any of the government plans.
A local healthcare administration expert contends that Missouri and Kansas are now on the losing end of that bottom-line argument.
At issue is emergency room care. Many people remember when the emergency room was where people went for a broken arm or a gunshot wound. Now it has turned into a default-free clinic for primary care - free to use but costly to maintain.
One reason for this is that federal law says hospital staff have to at least screen someone before referring them somewhere else.
"But by the time they get into it to actually find out, they may have already been through the most expensive part of your treatment anyway," said professor Suzanne Discenza, who heads up Park University's Masters of Healthcare Administration program.
She said the cost of providing primary care to the indigent in emergency rooms is one thing the Affordable Care Act was meant to address.
That changed when the Supreme Court decided that states could opt out of a key component of the legislation, which would have changed Medicaid's qualification levels.
"Mostly we are talking about the under-65 population," Discenza clarified. "Because at age 65, everybody is entitled to Medicare."
The difference between Medicare and Medicaid can be confusing for some.
Medicare is for everyone over the age of 65. It is run by and funded by the federal government. Medicaid is based on income. It is run by state governments and funded by both federal and state taxes.
Income restrictions for Medicaid vary by group. The elderly, children, pregnant women and the disabled qualify at higher incomes than others. In Kansas and Missouri, the need of parents of dependent children is measured well below the national poverty level.
In Kansas, the cut-off is at 32 percent of the poverty level, or $7,536 for a family of four. In Missouri, it is 19 percent, or $4,474 for a family of four. If people don't have children under the age of 19, they don't qualify at all.
The Obamacare insurance plans offer tax credits beginning at poverty level.
That is $11,490 for an individual and $23,550 for a family of four.
The original Medicaid mandate would have required Medicaid eligibility for all those below poverty level. Now, in Kansas, and most likely in Missouri, people in that gap will be right where they are now.
"You're going to have the same kinds of people who are going to be accessing the emergency rooms for the same types of reasons," Discenza said.
States which raise their Medicaid eligibility level will get the cost difference paid for by the federal government, at full cost to start, and never at less than 90 percent. At least that's what the plan says.
Based on that, Discenza said Missouri and Kansas are losing far more than they save by not taking that offer.
Still, taxpayers usually pay both federal and state taxes, so it would be fair to consider that taxpayers would be paying more either way.
Not true, argues Discenza.
She contends taxpayers and people already insured will end up footing a bigger bill if the Medicaid gap is not filled, because expanding Medicaid would, in theory, push people to doctor's offices, a much cheaper type of care than the emergency room.
"If we don't have Medicaid expansion, it means that you are going to continue to see your premiums rise," Discenza said. "In the long term you are going to see little bits and pieces of your income erode by having to still take care of others who access uncompensated care through emergency rooms."
The long term - and in theory - are important couching terms, because lawmakers who oppose expansion say they don't trust that the federal subsidy promises will hold up.
Conservative think tank The Cato Institute contends that expanding Medicaid will prompt people below the poverty level who are currently using workplace-funded insurance to ditch that plan in favor of a freebie.
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