The Joplin Globe, Joplin, MO

March 18, 2013

Gary Duncan, guest columnist: Expanding Medicaid right choice in Missouri

By Gary Duncan
Special to The Globe

JOPLIN, Mo. — The Missouri House  Budget Committee and the Senate Appropriations Committee turning down legislation recently authorizing Medicaid expansion that would have extended Medicaid coverage in Missouri to 138 percent of the federal poverty level is an issue that is important to all residents.

Strengthening Medicaid through federal funding available under the Affordable Care Act would have had major implications for Missouri’s mental health system.

If eligibility had been extended, nearly 50,000 of the 300,000 newly eligible Missourians would receive behavioral health services through Department of Mental Health funded community treatment and support programs.

Many will be young adults between the ages of 18 and 30 with developing mental illness such as schizophrenia or bipolar disorder. Missouri’s public mental health system does not currently serve them well because they are generally uninsured and have no means to pay for their treatment.

Through extended eligibility, community mental health centers and other DMH-contracted community behavioral health providers be able to engag individuals earlier in the onset of their mental illness or substance abuse. Through recent pilot programs, the Department of Mental Health and MO HealthNet (Missouri’s state Medicaid agency) have proved that early intervention and treatment result in better health outcomes at lower costs.

By extending Medicaid coverage, Missouri would have gotten back $1.8 billion of its federal taxpayer dollars in each of the first three years and $2 billion annually thereafter. A University of Missouri study says extending Medicaid in Missouri would generate 24,000 new jobs for the state in health care and related professions. Medicaid expansion will reduce the number of individuals who seek their health care through hospital emergency rooms, thus reducing the overall cost of health care.

As much as there would be a great benefit to the public mental health system by extending Medicaid coverage, there is an equally great danger for the system without the extension of Medicaid. The danger lies in the fact that to help fund extending coverage, federal reimbursements for uncompensated care of indigent hospital patients (often referred to as disproportionate share or DSH payment) will be reduced by 50 percent.

The Missouri hospitals that deliver inpatient services to uninsured and indigent patients receive over $500 million annually through DSH payments. So, those hospitals are going to lose $250 million in federal reimbursements annually for the charity care they provide, whether or not the state chooses to extend eligibility.

Without the extension, hospitals will be without the funding stream to cover the loss of their DSH payments. Therefore, hospitals will be forced to reduce services to indigent patients to make the necessary budget reductions. While the overall percentage of a hospital’s indigent patients may be small, the percentage of indigent patients served in its acute psychiatric units is much higher. These psychiatric units are most likely to be the place hospitals reduce or eliminate to compensate for the DSH loss.

Missouri has lost over 1,400 psychiatric hospital beds since 1990. This additional loss of acute psychiatric beds will create even greater problems for county sheriffs and city law enforcement departments that must transport these patients, often for long distances, in search of a psychiatric inpatient bed. Local law enforcement officers already stay at the hospital emergency rooms and inpatient units for many hours as these patients are admitted to care. This situation will worsen.

If community hospital psychiatric beds close, there will be increasing pressure on elected officials to open state acute psychiatric beds. The operating costs for state-operated acute beds would average approximately $850 per day, or about $31 million per year for every 100 beds, not including capital costs. Reduced federal DSH payments for state hospitals means that the costs of opening acute psychiatric inpatient beds would be borne primarily by state general revenue funding.

Strengthening Medicaid in Missouri would have enhanced public safety and improved public health by providing earlier intervention for people developing serious mental illness and substance use disorders. Not extending Medicaid eligibility will have a significant negative impact on Missouri’s mental health system, particularly on psychiatric inpatient services.



Gary Duncan lives in Joplin and is the retired CEO of Freeman Health System. He is a Missouri Mental Health commissioner.