Imagine walking into a fast-food restaurant with two cashier lines.
Above one, there's a sign reading, "This cashier has health care coverage." Above the other, there's a sign reading, "This cashier does not have health care coverage."
Which line would you choose? I'm going to take a wild guess that you'd select the covered one, unless the line was so long as to take the "fast" out of fast-food.
Public health connects everyone to everyone else. If you've followed the news recently, you might have noticed this principle demonstrated by the COVID-19 infection of more than 4.2 million Americans, with more than 147,000 deaths. In Missouri, the corresponding numbers are more than 44,800 reported cases and more than 1,200 deaths.
Hopefully, the realities of the pandemic will be on voters' consciences next Tuesday, Aug. 4, when they'll be deciding Amendment 2, which would expand Medicaid in accordance with the Affordable Care Act. Yes, that would be the dreaded Obamacare, which would provide 90 percent funding for expansion, reaping a huge net fiscal benefit to the state, according to a wide range of studies.
It shouldn't have taken a pandemic to drive home the basic truth that public health matters to everyone. In a kinder world, it would be unthinkable to place state budgetary concerns — especially distorted ones — above the fact that something like 230,000 people in Missouri make too much to qualify for Medicaid but too little to afford health care.
Consider this raw reality: In Missouri, a family of four must earn $5,500 or less to qualify for Medicaid and single adults don't qualify at all. This expansion would cover working people who earn up to a grand total of $18,000 for individuals and families of four up to $36,000. Can you imagine making less than such modest sums and being available to afford health care premiums?
If someone cannot afford health care, they are that cashier in the non-covered line. In turn, this person is the most likely to infect others in some way, pandemic or not, which is why everyone has a vested interest in their access to health care.
People with health insurance generally get free annual checkups. People without health insurance don't. People who have checkups are far more likely to catch and treat an illness than people who don't. People who stay healthy spread less sickness than people who don't.
Preventive care saves money and sometimes lives. It also prevents the spread of disease, say, to the insured person (and others) getting their food from the uninsured person. It doesn't take an expert in health care science to understand the basics here. A lot of this is common sense.
For example, we all know that people without health insurance aren't left to die in the street. When they become seriously ill, they go to emergency rooms and receive something known in the world of hospitals as "uncompensated care." When that happens, either taxpayers are left footing the bills, hospitals get closed down as collateral damage, or both.
The Chartis Group, a Chicago-based firm advising the health care industry, released a national study in February. It reported that a staggering 43 percent of 61 rural hospitals in Missouri were rated "vulnerable," tied for fourth highest nationally. The report said six rural hospitals had closed here in the past decade, tied for sixth in the U.S.
It's unbelievable, then, that people outstate have been persuaded to believe — purely through political rhetoric — that Obamacare must inherently present them some danger. To the contrary, expanding Medicaid can literally be a matter of life and death for outstate Missouri.
All that said, the economics are anything but simple, and the main argument that Republican legislators have espoused over the years is that a state like Missouri simply cannot afford the luxury of a healthier population. After all, the state has so many more important priorities like, well, whatever.
Their claim is that Medicaid expansion is unaffordable. When presented with the detail that Missouri is foregoing literally billions in federal tax dollars that Missourians pay in, they argue, irrationally, that some time down the road we'll end up holding the bag when the federal government goes out of business or ends Obamacare, whichever comes first.
For the moment, in the real world, there are 37 other states that have expanded Medicaid to qualify for their 90 percent federal share of the cost of doing so. That would include our neighboring radical hotbed of Oklahoma, where voters recently voted to expand.
To date, none of those states has chosen to change course after deciding to expand. None of them has declared bankruptcy. In all of those states, "more low-income children and parents, seniors, pregnant women, and people with disabilities are able to see a doctor when they are sick, get check-ups, buy medications, and go to the hospital," in the words of the Missouri Foundation for Health.
MFFH is a statewide not-for-profit that specializes in the highly complex world of health care matters, including economics, far above my pay grade. Here's how it breaks down those complexities:
"Research shows expanding Missouri's Medicaid program, MO HealthNet, would benefit our state economy," an MFFH position paper asserts. "It is estimated the economic output would increase by $2.5 billion and personal income would increase by $1.1 billion every year between 2022 and 2026. Especially as we continue to respond to the economic aftermath caused by the COVID-19 pandemic, any measure to kickstart our economy will be critical."
MFFH also claims the following:
"Research shows Missouri will have given up $17.8 billion in federal funding if we do not expand the Medicaid program by 2022," it states. "Federal funds would save our state $39 million in the first year of expansion, bringing tax dollars back home to help Missouri.
"By providing coverage to uninsured Missourians, Medicaid expansion will reduce uncompensated care and bring more revenue to clinics and hospitals, helping to keep them open and recruit new providers."
It is not clear how the politics of Medicaid expansion will play out Tuesday. In the past, reality has been distorted by politicians cashing in on the visceral unpopularity of all things Obama in outstate Missouri. That was an awful thing six years ago when Medicaid expansion first became a wedge issue, but at least it had a rational basis politically.
Now, to hold out petulantly is just immoral conduct, a fact magnified exponentially by the pandemic. That Governor Mike Parson chose to put Amendment 2 on the August ballot, rather than see it as a political base-driver for November, is a hopeful sign that the issue can no longer be so distorted.
But for those on the fence, those wondering if it's economically unrealistic to help more poor people get health care, I have a suggestion. Stop thinking about expanding Medicaid as bolstering a welfare program helping the poor.
Think of it as helping yourself.
Ray Hartmann founded the Riverfront Times in 1977. Contact him at firstname.lastname@example.org or catch him on Donnybrook at 7 p.m. on Thursdays on the Nine Network and St. Louis In the Know With Ray Hartmann from 9 to 11 p.m. Monday thru Friday on KTRS (550 AM).Correction: An earlier version of this story included an incorrect figure for the number of coronavirus cases in Missouri. We regret the error.