Show Me Medicaid Expansion for Rural Missouri

Adrienne Visani, current student; and Evaline Xie and Kristine Huang, incoming students, all at the Washington University School of Medicine in St. Louis


In the upcoming August 4th election, voting to expand Medicaid in our state is making the right choice for rural Missouri.

Constitutional Amendment 2 would expand Medicaid eligibility to adults making up to 138% of the federal poverty level ($17,608/year for individuals or $29,974 for families of three). These are people making too much to qualify for Medicaid but unable to afford private insurance on their own. Of the uninsured, 80% are currently working, but for employers who don’t provide insurance. Others can’t work due to life circumstances, such as illness, disability, or taking care of a sick family member. In the last few months of COVID-19 layoffs, 100,000 more Missourians have lost insurance. Expanding Medicaid would cover 34,000 of Missouri’s essential workers keeping us afloat during the COVID-19 pandemic.

Rural Missouri stands to benefit even more from Medicaid expansion–a disproportionate number of the 230,000 Missourians newly eligible will be from rural areas. Rural Missourians tend to have more chronic conditions and fewer doctors and rely on smaller hospitals offering fewer services compared to their urban counterparts. Our rural counties of Taney, Butler, St. Francois, Howell, and Dunkirk have the highest rates of uninsurance in Missouri, with roughly 40% of low-income adults uninsured last year. Expanding Medicaid would benefit more rural constituents than St. Louis and Kansas City combined.

Medicaid expansion would also boost the financial health of rural hospitals by covering more patients—uninsured patients usually can’t pay hospitals back for the full cost of care. Nationwide, hospitals have spent half as much on caring for uninsured patients after their states expanded Medicaid. Rural hospitals can’t afford to lose more money: In the last five years, seven of Missouri’s rural hospitals have already closed, and those remaining are six times more likely to close if Missouri doesn’t expand. Extreme reductions in cash flow during the COVID-19 pandemic only worsen this threat.

Hospital closures have serious consequences for the whole community–even for those with top-notch insurance. Everyone in the region would have to travel farther (usually some 20-30 miles) to receive care. Someone having a stroke or bleeding out from a farming accident can’t afford that extra time. A woman in labor with a breech baby can’t afford that extra time. Hospitals also provide jobs and stimulate the local economy by attracting skilled laborers and outside investment. Closing the sole hospital in a rural community increases unemployment and costs the average resident more than $700/year.

Voters in the “Show Me” state can look to our neighboring states to see the benefits of Medicaid expansion. In these states, the uninsurance rate for low-income, rural residents was cut in half after expansion. Since Kentucky and Arkansas expanded Medicaid, residents now have more personal physicians, skip fewer medications, and visit the emergency room less than people in non-expansion states. Women with breast cancer in states that expanded are diagnosed at earlier stages. Overall, people in expansion states felt their health decline less over time.

These improvements have actually created financial savings by bringing federal tax dollars back to states and reducing medical costs by expanding access to preventative care. Kentucky achieved one of the most dramatic improvements in coverage while saving the state $100 million and creating 12,000 new jobs in the first year after expansion. Louisiana and Montana have also seen significant savings. Expanding Medicaid in Missouri could save the state an estimated $39 million by the end of 2020, with more savings in the future. It would also create 16,000 jobs in the first year alone, 64% of those jobs outside St. Louis and Kansas City.

Most other states with large rural populations like Missouri have already expanded Medicaid. Arkansas, Idaho, Iowa, Kentucky, Minnesota, Montana, Nebraska, North Dakota, and Ohio are among the 37 states already on board. Just last month, our neighboring Oklahomans joined them.

Now it’s our turn. Healthcare in rural Missouri faces an uncertain future, but Medicaid expansion offers us an opportunity to keep hospitals afloat, improve rural health, and bring tax dollars back to our state. Our neighboring states are seeing the benefits of Medicaid expansion, and August 4th is Missouri’s chance to join them.