As we move into the final weeks before the Nov. 8 election, Democratic gubernatorial nominee and Attorney General Chris Koster is making a point to separate his political stances from the actions of the Missouri General Assembly.
In a graphic posted on Instagram, Koster’s campaign wrote, "The legislature’s failure to expand Medicaid has brought crisis to many of Missouri’s rural health care providers."
That sounded pretty dramatic, so we decided to look into the claim.
The post referred to research done by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. The Koster campaign also directed us to an article from the Springfield News-Leader.
What we found in examining the evidence is that not every hospital Koster cited is "rural," and the hospitals closed for a variety of reasons.
Cecil G. Sheps Center Report
The Sheps Center has tracked hospital closings in the continental United States since 2010. In that amount of time, three rural Missouri hospitals have closed, the center reports.
The Sac-Osage Hospital in Osceola closed in September 2014, the Parkland Health Center Weber Road in Farmington closed in January, and the SoutheastHEALTH Center of Reynolds County in Ellington closed in March.
Koster’s campaign also directed our attention to the Ozarks Community Hospital in Springfield, which closed its surgery department and emergency room in July. The Ozarks Community Hospital is not considered a rural hospital because it’s located in Springfield, population 160,000. The hospital contained 45 beds, plus 10 more in its geriatric psychiatry unit, a small number for a city of that size.
If we start counting in September of 2014, these four closings work out to approximately one every eight months. But, again, while the Ozarks Community Hospital is small, it’s not rural.
According to Ryan Barker at the Missouri Foundation for Health, Missouri could have expanded Medicaid starting Jan. 1, 2014, before any of the hospitals closed. Expanding Medicaid would have had a significant impact on the reimbursement of health care providers. Dave Dillon, a spokesman for the Missouri Hospital Association, told St. Louis Public Radio that the legislature’s decision to not expand Medicaid will cost Missouri $4 billion in federal payments over the next six years.
Under the Affordable Care Act, states were given the opportunity to expand the pool of citizens covered by Medicaid, a subsidized insurance for citizens living in poverty. The federal government would have covered the entire costs of the broadened coverage for the first three years, but the level of federal subsidy would decline after that.
Legislators in Missouri and 18 other states chose not to expand Medicaid, in part because of the greater costs to the state, but also because of ideological opposition to subsidized insurance and Obamacare.
Since many rural hospitals were already in crisis before 2014 because of a large burden of uninsured patients, the failure to expand Medicaid isn’t the direct cause for closings. However, Medicaid expansion was a missed opportunity to lessen the load on those affected hospitals.
Why the hospitals closed
In an article from the Kansas Health Institute News Service, Chris Smiley, the CEO of the Sac-Osage hospital, said the hospital was forced to close because of a large amount of uninsured patients and shrinking payments from Medicare.
"Hospitals expected to see millions of newly insured customers thanks to federal subsidies enabling people to buy health insurance and the expansion of state Medicaid programs," explained the article. "In exchange, they agreed to accept reduced Medicare payments and a huge cut in disproportionate share hospital, or DSH, funding, which the federal government pays to offset the costs of uncompensated care."
Since Missouri opted out of Medicaid expansion, this left the hospital with a gap in reimbursement.
The closest hospital to Osceola is now Ellett Memorial Hospital in Appleton City, 30 minutes away.
Parkland Health Center Weber Road officials were much less specific in their explanation, but said that concerns about building safety and regulations factored in the decision to close.
Most of the hospital’s services, including emergency care, have since been relocated to other Parkland Health facilities, also located in Farmington.
SoutheastHEALTH was forced to close because of a $6 million debt owed by Advanced Healthcare, the previous owner of the hospital. As the owners of the property, state Medicaid officials informed the company that it was liable for the debt.
The nearest hospital to Ellington is now the Iron County Hospital in Pilot Knob.
Ozarks Community Hospital was forced to close its ER and surgery center because the Centers for Medicare and Medicaid Services determined it did not have a large enough inpatient population to be considered a hospital.
Since approximately 40 percent of the hospital’s patients were uninsured and it was being paid less money to treat them, the hospital was only able to admit patients following surgery by 2015, according to OCH Health System owner and CEO Paul Taylor in a Springfield News-Leader article.
He said there is "no doubt in my mind" that the hospital would have stayed open if Missouri had expanded Medicaid.
The Ozarks Community Hospital now functions as a clinic.
Koster said, "A rural hospital in Missouri closes every 8 months. The legislature’s failure to expand Medicaid has brought crisis to many of Missouri’s rural health care providers."
Koster’s claim is a bit of stretch. Four small Missouri hospitals have closed entirely or in part since September 2014, three of which are rural. In half those cases, patients being unable to pay their bills was cited as a reason for the closure. And many of those patients likely would have been covered had Missouri expanded Medicaid.
Koster’s statement is partially accurate but leaves out important details. We rate it Half True.
Instagram post, @koster4mo, Aug. 9, 2016
Interview, David Turner, spokesman for Chris Koster for Missouri, Sept. 17, 2016
Email interview, Ryan Barker, Vice President of Health Policy at the Missouri Foundation for Health, Sept. 6, 2016
Email interview, Christopher Wickle, Professor at the University of Missouri Department of Statistics, Sept. 6, 2016
Map of Medical Facilities in Missouri, Missouri Department of Health and Senior Services
Rural Hospital Closures, Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill
Article, Southeast Missourian, Feb. 10, 2016
Article, Kansas Health Institute, Feb. 11, 2015
Article, St. Louis Business Journal, Dec. 9, 2015
Article, Reynolds County Courier, Feb. 17, 2016
Article, KFVS 12 News, Feb. 9, 2016
Article, Springfield News-Leader, Aug. 4, 2016
Article, Springfield News-Leader, July 18, 2016
News release, OCH Health System, July 26, 2016
Article, St. Louis Public Radio, March 26, 2014
MO Hospital Profiles by County, Missouri Department of Health and Senior Services, Sept. 7, 2016
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