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In States Like Missouri And Kansas That Didn’t Expand Medicaid, Residents Carry Higher Medical Debt

Alex Smith
KCUR 89.3
Geneva Wilson keeps a chicken and rooster in a coop behind her cabin in rural southwest Missouri.

Geneva Wilson has struggled her entire life with health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia. But she’s found peace living in a small cabin in the woods of western Missouri.

Wilson keeps chickens, raises rabbits and has a garden. She says her long-term goal is to live off her land by selling what she raises at farmers’ markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements have kept her from getting public assistance. Since graduating from college 20-plus years ago, she’s mostly had to pay out-of-pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson says.

Wilson says she lives on $300 a month sent by her mother in Florida. Her medical debt stands at about $3,000, which she pays at the rate of $50 a month.

She desperately needs a hip replacement, but she canceled the surgery because, even with deeply discounted charity care from a nearby hospital, she can’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson says. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as their illness. The good news is that medical debt has been on the decline in recent years. The less good news is that recent research shows the rate of decline is tied to whether a state has expanded its Medicaid program.

In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th highest rate.  

Researchers Aaron Sojourner and Ezra Golbertstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7 percentage point reduction,” Sojourner says.

But in expansion states?

“Where they did expand Medicaid, it fell by almost twice as much,” Sojourner says.

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute.

Medicaid, as opposed to private insurance, is the key, says The Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if a Medicaid patient needs a lot of care, she isn’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect that their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell says.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what of we’re seeing in our paper,” Caswell says. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

Efforts to repeal and replace the Affordable Care Act are probably finished this year. That means legislators in Missouri and Kansas – and the remaining 17 non-expansion states – could conceivably take up the question of expanding Medicaid eligibility in 2018.

As Geneva Wilson tends to her chickens, she says she tries not to think too much about her medical debt or how she’ll pay for that much-needed hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive. ’Cause I can’t manage,” she says.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts.

Now there’s not much left to sell except her cabin and her land. 

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson says. “It’s hard losing your dreams.”

Alex Smith is a health reporter for KCUR. You can reach him on Twitter @AlexSmithKCUR

As a health care reporter, I aim to empower my audience to take steps to improve health care and make informed decisions as consumers and voters. I tell human stories augmented with research and data to explain how our health care system works and sometimes fails us. Email me at alexs@kcur.org.
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