Last year Hattie Saltzman was a 19-year-old diabetic in Kansas City who had to choose between her education and her insulin.
Trapped in an individual health insurance plan with high-co-pays and deductibles, Saltzman contemplated dropping out of the University of Missouri-Kansas City for a semester so she could afford to buy more medicine.
Instead, she tried to keep taking 17 credit hours and waitressing, while rationing her insulin to make it last longer. She made one batch last too long. By the time she took it, it had expired. Her blood sugar soared and she ended up in the emergency room.
“I was walking the line because of my rationing,” Saltzman said. “I was walking the line in between health and death, basically.”
Star readers responding to a survey for the Missouri Influencers series said the most important health care question is what policymakers can do to lower costs and make it accessible for all, including those with pre-existing conditions.
The Influencers — the Star’s panel of dozens of leaders from across the state — set out to answer the question. Most said solutions lie in either expanding government coverage or requiring more transparent prices.
Saltzman got help from her church and this year is in a federally-subsidized health plan with better coverage. But she knows there are people throughout Missouri living every day the way she was last year, barely getting by.
“It’s ridiculous that in the United States, of all places, people can’t afford the things that make them healthy,” she said.
It’s no surprise that Missourians are concerned about health care costs. According to a study released by the Urban Institute last year, Missouri ranks seventh in the country in percentage of working-age adults who have past-due medical debt, at more than 30 percent.
Only Mississippi, Arkansas, West Virginia, Indiana, South Carolina and Kentucky were higher.
Missouri is one of 17 Republican-led states that have so far opted not to expand Medicaid under the Affordable Care Act, commonly called Obamacare.
Expanding Medicaid would cover some of the 12 percent of working-age Missourians who are uninsured, and some preliminary studies have shown that states that expanded Medicaid reduced low-income residents’ medical debt and medical bankruptcies.
Kansas City Councilwoman Alissia Canady was one of several Influencers who said the state should accept expansion.
“The most pressing issue in Missouri is the number of uninsured residents and limited access to care in rural areas,” Canady said. “Missouri lawmakers should expand Medicaid.”
Other Influencers, such as lobbyist and former Missouri Republican Party chairman Woody Cozad, said expanding Medicaid would be too expensive and would crowd out other state services.
“Everything the government says it will help us afford becomes unaffordable,” Cozad said. “The most expensive things in our lives are higher education, houses, and health care. The government has been ‘helping us’ pay for all three for about seventy-five years. Another twenty-five years of Washington’s help and we’ll all be bankrupt.”
Covering people who are uninsured will only go so far in addressing Missourians’ health care cost worries. The Urban Institute study found that a significant portion of the people struggling under medical debts are insured but, like Saltzman, have plans that include out-of-pocket costs that are increasingly hard to bear.
Former state senator Ryan Silvey was one of several Influencers who said more transparency in health care pricing is what Missourians need.
“Under the current system, most people have no idea what the true cost of their healthcare is because most bills are circulated within the system itself and the consumer only becomes aware after the fact when they are presented with what’s left,” Silvey said.
Missouri legislators passed a health care pricing transparency bill in 2014, spearheaded by Missouri Sen. Jason Holsman, a Democrat from Kansas City.
But Rockhurst University professor Jim Dockins said that bill only “helped a micro amount.”
“(It was) way too little and way too watered down by hospital and insurance lobbies in Jeff(erson) City,” Dockins said via email.
Dockins praised several direct primary care practitioners — doctors who don’t take insurance and instead are paid by monthly fee — for their efforts to increase price transparency.
Maine and New Hampshire earned high marks from Altarum, a health care consulting firm, for their health care pricing transparency laws. Missouri, on the other hand, was one of 43 states that got an “F” on the group’s report card.
Dan Munro, a national expert on health care payer models, said costs are hard to control in the U.S. health system not because of a lack of transparency but because, unlike in other developed nations, the cost of care in the U.S. depends entirely on who’s paying.
Medicaid pays providers less for the same services than Medicare does. Medicare pays less than private commercial insurance. Even within commercial insurance there’s a wide range of prices depending on the plan. Uninsured patients generally are charged list price — which is more than all three.
It’s a “tiered” pricing model in which some payers are subsidizing others and it doesn’t make sense, Munro said.
Rather than arguing about single payer health care, which is politically divisive, Munro said policymakers should be talking about moving to “single pricing,” where the rates are the same for all consumers. Prices will be lowest when all consumers, regardless of who covers them, are negotiating as a single bloc, he said.
“The key is single pricing and what delivers that is universal health coverage,” said Munro, the author of a book called “Casino Healthcare” about the U.S. system. “Who pays for that, whether it’s single payer or multi-payer, is immaterial.”
Munro said states should treat health care more as a regulated public utility like electricity — with centralized price-setting — rather than as a consumer product.
Maryland has moved to that model for inpatient hospital care, but Munro said that’s not enough to control costs. Prescription drugs and outpatient medicine has to be included, too.
Even if Missouri is able to reduce costs, access to care will remain an issue, especially in rural areas, where providers are becoming fewer and farther between.
Four Missouri hospitals have closed since 2010, and the Missouri Foundation for Health estimates that nearly half of the rural hospitals left are operating at a financial loss.
Telemedicine is increasingly being touted as a way to fill the gaps, but details need to be worked out in terms of physician licensure and insurance reimbursement, and in some areas rural broadband access isn’t robust enough to support reliable videoconferencing.
Michael Barrett, the director of Missouri’s public defender system and one of the Influencers, floated another idea: expanding the care provided by people who aren’t doctors but who have medical training.
“Need to deploy nurses and other health care professionals to underserved areas to deliver preventative care,” Barrett said. “Run a pilot (program) in three counties and track results and costs.”
There are no easy answers, said Jean Paul Bradshaw, an attorney at Lathrop Gage and an Influencer.
“Be honest with people that it is expensive to provide health care at the highest level, rather than lead people on that there is a simple solution,” Bradshaw said. “It is a complicated system and reform is not easy.”
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Former Gov. Eric Greitens locked the press out of his communications office. Dark-money groups aided his rise, and some of his staffers used an app that immediately deletes messages in an apparent effort to skirt public records laws. Now, there’s a new administration, but still critics question some Missouri laws, including allowing lawmakers to accept gifts from lobbyists. What questions do you have about political corruption and transparency in Missouri? Tell us at KansasCity.com/Influencers