Community Building Organizations Should Support Medicaid Expansion in Missouri

Terry Weiss, MD, FACR Member, Provider Services Advisory Board St. Louis Regional Health Commission, Co-founder and Past President, St. Vincent Greenway, Inc.

Every decade since the Theodore Roosevelt administration (1901-1909) the federal government has made an effort to reform the U.S. health care delivery system. The underlying premises have been: 1) health care is a right, not a privilege, and 2) ʻOne can judge a nation by how it treats its most vulnerable citizensʼ (Aristotle).

In 2010 the U.S. Congress passed and President Obama signed into law the Patient Protection and Affordable Care Act, aka the Affordable Care Act (ACA) or “Obamacare.” The goals were to expand coverage, improve quality of care, and lower costs. A principle mechanism for expanding coverage to millions of uninsured Americans is the expansion of Medicaid. Missouri is one of 26 states which has refused to do so. Community organizations should care because of the implications of expanding or not expanding Medicaid.

From the medical standpoint the benefits of expansion include increased access to health care, especially for parents (working and non-working).  Another benefit is preventive care, e.g., vaccinations and disease screening. Medicaid expansion would enhance early detection and treatment, a category in which Missouri ranks thirty-eighth.  What are the implications? Take high blood pressure (hypertension) as an example. Hypertension is an asymptomatic disease. One can have a BP of 150/110 (normal is around 120/80) and feel quite normal. However, untreated hypertension can result in kidney failure, heart attack, or stroke. Which is better and more cost effective? To treat the person with asymptomatic hypertension or wait until the individual has kidney failure and needs dialysis, has a stroke and needs extensive, perhaps life-long care and may be unemployable, or has debilitating heart disease? Finally, there is an emphasis on quality of care through the Agency for Healthcare Research and Quality established by the ACA.

There are many economic benefits of expanding MoHealthNet, Missouri’s Medicaid program. First, as noted above, increased accessibility, prevention, early detection and treatment will lower health care costs. Second, while the state will invest $431 million between 2014 and 2019 it will receive $94 billion federal dollars over 10 years. Most of the funds to pay for the expansion are federal. The federal government will pay 100% of expansion costs through 2016, 95% of costs in 2017-2019 and 90% thereafter in perpetuity. There will be job creation. Had the legislature expanded MoHealthNet in 2013 there would have been 24,000 more jobs in Missouri in 2014, 5,000 of them in the St. Louis area. These are good, well paying jobs, e.g., for construction of health care facilities, laboratory technicians, pharmacists, nurses, nurses aids, etc. These jobs would also generate substantial state tax revenues.

Lastly, expansion is critical to survival of rural hospitals and health systems. Hospitals currently receive extra federal payments for providing care to the uninsured. Providing such care gives those hospitals a disproportionate financial burden and the extra moneys are referred to as ʻDisproportionate Shareʼ funds (DSH, pronounced DISH). One way the federal government plans to pay for Medicaid expansion is by reallocating DSH moneys from states not expanding Medicaid to those that do. This loss of funds to small  Missouri hospitals will be crippling or even fatal to preserving service in rural and poor areas.

Like Medicaid, community development corporations (CDCs), neighborhood associations, and other community building organizations serve the underserved and work toward creating opportunity and a higher quality of life for all. Community building organizations’ constituents include a large number of those who would benefit from MoHealthNet expansion. Collaboration between community building organizations and those seeking to expand Medicaid is a natural. You can help:

• Your CDC, neighborhood association, and the CBN could pass resolutions supporting MoHealthNet expansion;

• You can join the Missouri Medicaid Coalition: http://www.momedicaidcoalition.org/;

• You can send your resolutions to your legislators and to the Coalition;

• You can write letters to the editor and to your legislators telling them why you support expansion:

• If you have residents who have stories to tell about their difficulties with lack of insurance you can encourage them write up their stories and submit them to the Coalition.

Join in the struggle, as you do every day in other ways, to improve the quality of life for your constituents. Join in the effort to expand MoHealthN

Articles in “From the Field” represent the opinions of the author only and do not represent the views of the Community Builders Network of Metro St. Louis or the University of Missouri- St. Louis.

The Case for Participatory Budgeting in St. Louis

By Zach Chasnoff is a community organizer Missourians Organizing for Reform and Empowerment (MORE) working for economic and social justice in the City of St. Louis.

We are living in exciting times. Vibrant public discourse about the transparency of our government and the average citizen’s ability to access those systems of governance is happening on national and local levels.

The City of St. Louis is no exception. We have been grappling with this issue in the form of very low voter turnout and engagement as well as a lack of oversight, or even basic understanding, of how the city operates. As a community we are searching for solutions to both the problem of transparency as well as the problem of getting real, engaged citizen participation.

One answer has already made waves in some parts of the country and accomplished big things here in the 6th ward.  It’s called Participatory Budgeting (PB). PB is a structured, step-by-step process by which citizens get a direct vote in how pots of public money are allocated. Through a bottom-up process, citizens decide what community projects are needed, determine a budget for expenditures of available ward funds, and work with city agencies to see the projects through to completion.

Starting in Brazil in 1989, Participatory Budgeting first appeared in the United States in Chicago’s 49th ward. After its successful implementation there, several other Chicago wards followed suit. Shorty thereafter PB was implemented in multiple New York City Districts. Later the entire city of Vallejo California turned over its budgetary decision making to its residents through Participatory Budgeting. 

Brad Lander, the Council Person in New York City who initially implemented PB there, first introduced the idea to a St. Louis audience at the 2012 SLACO conference.  A buzz was created in the city when Michelle Witthaus ran against Christine Ingrassia for 6th ward Alderman on a platform of direct democracy that included PB. Ingrassia won that race but believed enough in Participatory Budgeting that she reached out to Michelle so that they could work together to implement it.

PB is correlated with increased citizen participation. The Participatory Budgeting Project in New York states:

One of the most striking findings about who participated in PB is how the data compares to other types of civic engagement, particularly voting patterns in NYC elections. Across the districts, PB engaged communities that have traditionally been uninspired by politics. People of color, low-income people, and some immigrant groups turned out at higher rates than in previous elections. More than just getting people to vote, PB deepened the connections between residents and government.

In Chicago residents report that “…with this approach the people wielding power are not the rich or well-connected. Instead, they’re regular citizens who choose to put in the time.”  This is civic empowerment that transcends the budgetary arena.

Working together, Alderwoman Christine Ingrassia, Missourians Organizing for Reform and Empowerment (MORE), Participatory Budgeting St. Louis (PBSTL) and 6th ward residents have recently completed the first phase of the first-ever PB process in St Louis. Turn-out has exceeded expectations and is representative of the racial and economic diversity of the area. Residents will move to vote on the allocation of 40% of the annual ward budget in capital funds by April of 2014.

PBSTL recently announced planned implementation in Scott Olgilvie’s 24th ward. Our goal for 2014 is to have Participatory Budgeting in four wards total by the end of the year. For this program to have a true impact on the city as a whole it needs to be in as many areas as possible. PBSTL is also interested in moving the process beyond the allocation of capital funds and into exciting diverse city arenas such as the Land Reutilization Authority (LRA) and HUD allocation of Community Development Block Grant (CDBG) funds.

One of the many beauties of Participatory Budgeting is its elasticity.  A 6th ward steering committee has tailored the process to meet the unique qualities of their ward but the process will look a little different in the 24th ward and can be tailored to the CDBG process just as easily.  For instance, organizations could submit their applications and St. Louis residents could be allowed to vote on the projects that they wanted most. Working with community organizations to get the word out will ensure diverse and meaningful participation from all sectors of the city population. The most important thing is that we get a broad spectrum of St. Louis citizens engaged and excited about civic participation.

Participatory Budgeting is by no means a silver bullet that will cure all of our civic woes, but it does open previously closed doors and provides clear one-to-one correlations between citizen input and tangible results. St. Louis has the chance to be a national leader in an exciting innovation. If transparency is the goal, then let’s open up the process.  If we want to hear what the people of this city have to say, let’s listen to them, and let’s give them a vote.

For more information on Participatory Budgeting please contact PBSTL at pbinstl@gmail.com.

Articles in “From the Field” represent the opinions of the author only and do not represent the views of the Community Builders Network of Metro St. Louis or the University of Missouri- St. Louis.

Measuring CDFIs Impact…and Then Telling Everyone You Know

By Colleen Kirby, Asset Manager, Compliance, St. Louis Equity Fund, INC

Leaders in community development have called Community Development Financial Institutions (CDFIs) the “next big thing” in community development (CD) finance. They say that what the Low-Income Housing Tax Credit (LIHTC ) has done over more than 25 years for affordable housing development, CDFIs will do for financial products and services. Yet, this “next big thing” has actually been around for more than 15 years and St. Louis is home to several CDFI credit unions and loan funds. Why then do so few people, even in the CD world, know what CDFIs are, and understand the impact they have on our communities?

A little background first. CDFIs fall under a division of the US Treasury (The CDFI Fund) which was created out of a 1994 bipartisan initiative to promote economic opportunity and community development in underserved communities. Many CDFIs existed before the creation of the CDFI Fund, though now they were being officially recognized by the Treasury as an important piece of the community development puzzle. CDFIs complement rather than compete with traditional banks and lenders. The CDFI Fund certifies entities that provide these products and services, and Missouri is home to 24, three of which are loan funds, the rest of which are banks, depository institutions and credit unions. To be certified an organization must show that it offers financial tools and development services that are focused on serving the community development finance needs of a specific target market.

Great, so it sounds like CDFIs would be a big benefit to our communities – but who are the CDFIs in our region and what do they do? Why are these organizations still flying under the radar? Can they really be the “next big thing” for St. Louis? A coalition of CDFIs serving Missouri has recently been formed and one of the goals is to ensure our missions are known and our investments can grow.

The three Missouri-based loan funds, International Institute CDC, Great Rivers Community Capital, and Gateway Community Development Fund, Inc. all focus on different aspects of CD finance by providing micro lending to new immigrants and small businesses, and real estate loans to developers of affordable rental housing. IFF, a large CDFI based in Illinois but with a presence in St. Louis, also provides housing developers with loans, as well as financing for charter schools, community health centers, and vehicles. CDFI credit unions, like the St. Louis Community Credit Union, focus on providing crucial financial products and services to under banked and economically disadvantaged families and individuals coupled with financial education.

The only way these organizations can  truly change the way financial products and services are delivered in our region is if they are able to grow their capital base and expand their lending and service provision to even more corners of each CDFI’s “target market”. To do that, they need consistent investment by traditional financial institutions, which may be motivated by Community Reinvestment Act (CRA) requirements.  But investors can also be enticed by good returns and reasonable risk, as well as recognition of their impact by key players in the communities they serve. This means making sure elected officials, business, education, and civic leaders know about the work of CDFIs .  

More importantly, CDFIs themselves must tell their stories, and not just to those outside the CD world. We have to measure and report on our progress toward our missions, analyze the impact we have on our target markets, and evaluate the opportunities for improvement by listening to our customers and communities. CDFIs must also identify concrete indicators of success. Results-driven funders want to know exactly how their investment improves the financial well-being of the individuals and communities they wish to serve.  If we listen to the communities we serve, identify success stories, and tell each other as well as the outside world, then CDFIs really could become “the next big thing” in community development.

Articles in “From the Field” represent the opinions of the author only and do not represent the views of the Community Builders Network of Metro St. Louis or the University of Missouri- St. Louis.