While traveling through Kansas talking about health care, David Jordan has heard story after story about people drowning in a sea of medical bills they can't pay.
So Jordan, the president of the United Methodist Health Ministry Fund, said he wasn't surprised when one of the largest surveys of Missouri and Kansas health care consumers ever conducted showed that medical debt was one of their top concerns.
"One story comes to mind," Jordan said. "In Pratt, Kansas, the owner of a property rental business, in the context of Medicaid, highlighted that oftentimes her tenants are choosing between paying their rent and paying their medical bills. They struggle with this decision and one month they might pay their medical bills and other months they might choose to pay their rent. As a result, oftentimes she has a third to half of her accounts defaulting."
The survey of 4,274 people was commissioned by five nonprofit health foundations and conducted in 2017 by the Research Triangle Institute.
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It found that 33 percent of Kansas kids and 28 percent of Kansas adults lived in a household that struggled to pay medical bills the year before. In Missouri, it was even more common, with 38 percent of kids and 34 percent of adults in households that struggled with bills.
Almost 20 percent of respondents in both states said they had faced financial consequences from medical debt, either asking family and friends for help, seeking personal loans or getting hounded by debt collectors.
The survey results come on the heels of an Urban Institute study released in December that showed that in some areas of Kansas City, about 30 percent of households have medical debt in collections.
Jordan said that can have a ripple effect on local economies by harming credit ratings while also making people less likely to seek medical care.
"Medical debt and lack of insurance is financially crippling families in Kansas and Missouri," Jordan said.
The survey showed that about 20 percent of adults ages 19 to 64 in both states are uninsured, and about 60 percent of them are working. The uninsured rate in children, who are often eligible for Medicaid, was much lower.
Uninsured rates were slightly higher for black Kansans and Missourians than whites, but markedly higher — about 50 percent — among Hispanics.
"The stark rate of Hispanics who are uninsured has to be called out," said Bridget McCandless, the president and CEO of the Health Care Foundation of Greater Kansas City.
Jordan and the leaders of the various health foundations have advocated for the legislatures of both states to expand Medicaid to low-income adults under the Affordable Care Act. A majority of states have expanded and Jordan said they have higher insured rates and lower rates of medical debt.
Medicaid eligibility in Kansas and Missouri is currently restricted mainly to children, the elderly, people with disabilities and pregnant women.
Legislators who oppose expansion under the ACA, commonly called Obamacare, have said Medicaid should remain a program for those populations. They also balked at the expense of funding expansion, which requires states to shoulder up to 10 percent of the costs.
Being uninsured is not the only factor in medical debt, though. The survey's authors said some respondents who reported being insured also reported struggling to pay medical bills, though they had not broken out what percentage yet.
Sheldon Weisgrau, the director of a grant-funded program to get Kansans signed up for health insurance, said higher deductibles and co-pays mean even people covered under private insurance plans often find themselves with bills they can't easily pay.
"Under-insurance is a huge problem," Weisgrau said.
McCandless said nonprofit hospitals can help ease the problem in the Kansas City area.
As part of the "community benefit" they must show to keep their tax-exempt status, nonprofits are supposed to write off or write down some bills for low-income residents.
McCandless said she thought hospitals have improved their record of doing that, but "still have room to go."
"As hospitals are making more financial decisions around their bottom lines, it is critical that we as taxpayers continue to make sure that that community benefit returns to the community," McCandless said.
In addition to medical debt, Kansans and Missourians reported problems accessing some types of medical services.
Lack of dental insurance was a problem in both states, and so was access to mental health care.
People who couldn't get mental health care said they either could not afford it, could not find a provider who takes their insurance, could not find a provider who had an opening or didn't know where to find care.
Brenda Sharpe, the president and CEO of the REACH Healthcare Foundation, said she hoped those responses will push lawmakers to expand access to mental health.
"This is a hot topic in both states," Sharpe said. "But we've seen very little action."