‘I don’t want to bankrupt my family’: Missourians in Medicaid gap worry about health, finances

Terry Knowlton has had a sobering thought on her mind as confirmed coronavirus cases continue to grow by leaps and bounds.

“If I were to come down with COVID-19, to the point where I have to go on the respirator, let me go,” Knowlton said. “Don’t put me on anything because I don’t want to bankrupt my family because I got sick, and that’s exactly what would happen.”

A Springfield resident for over 30 years, Knowlton, 55, lives with her husband, 12-year-old son and pet chihuahua. Until recently, she was employed as a part-time dispatch operator for a small trucking company. At the onset of the pandemic, the company’s lone driver decided to retire, which left her unemployed.

Terry Knowlton | Courtesy of Knowlton

Perhaps even more concerning was the fact that Knowlton was also uninsured, and had been for some time. While her husband and son have insurance coverage through the Department of Veterans Affairs, she is in a gap. She and her husband have too much joint income to qualify for Medicaid, the government health insurance program for people with low incomes or disabilities, but too little to reasonably afford any other form of insurance coverage.

“That’s the hardest thing, being so close and not being able to get any kind of insurance coverage that we can afford,” Knowlton said. “So if they were able to expand, then I would have some kind of peace of mind that I’ve got the ability to go see a doctor without having to take out a loan.”

Knowlton is one an estimated 230,000 Missourians living in that Medicaid coverage gap who would be eligible for benefits if an amendment to expand Medicaid care in the state is approved in Tuesday’s election.

If approved, Amendment 2 would increase Medicaid access to individuals making up to 138% of the federal poverty line — or nearly $18,000 a year. A family of four could make slightly more than $36,000 a year and still be eligible.

Under Missouri’s current Medicaid plan, about 940,000 people, or 15% of the state’s population, were covered as of June. Eligibility for this plan is available to a family of four with an income of less than $5,550, or certain individuals with special circumstances, such as pregnant women or people with disabilities.

In total, there are about 564,000 uninsured people in Missouri, so the 230,000 who would become eligible for insurance under Medicaid expansion could reduce the state’s uninsured population by 41%.

“When you have hundreds of thousands of people who cannot get health care, and it’s really not because they’re not hardworking or they’re not interested in it or they don’t want to take care of their families,” said Nancy Kelley of the Missouri Foundation for Health. “It’s really about the system not allowing them to do that practically.”

A study from Washington University in St. Louis found that the current Medicaid program is still using income requirements from 1996. At that time, $5,550 was equal to about 35% of the federal poverty level. With the inflation since then, it is now equal to about 19% of the poverty level.

“It’s so hard to keep your income that low, because it’s hardly any money at all in real terms,” said Abigail Barker, a professor at Washington University in St. Louis who has published research on people living in the gap of Medicaid coverage. “So even if you maybe have some sort of health condition that prevents you from working full-time or from working a job where you could earn a decent wage, but you’d still like to supplement your income, this restriction makes it very challenging.”

In 1990, Missouri was ranked 24th in the nation for the overall health of its residents, according to America’s Health Ratings. In the past 30 years, the state has slid down the ranks to 39th in overall health.

By increasing the limits for Medicaid eligibility, Missouri would open the door to people who have been seeking health insurance coverage but found no viable options.

That has been the case for Kaylei Ramis, who has been without insurance since she began supporting herself financially at 18. Ramis, now 21, is a senior at Stephens College in Columbia, studying event and convention management.

“When I turned 18, I was looking for ways to have health insurance and learned that you can’t have Medicaid if you’re over 18 unless you’re pregnant or have a child,” Ramis said, “so I haven’t had any insurance since then.”

Although she has not had any major health emergencies, Ramis still has concerns about any health issues that could arise.

“I just get worried, like if I was in a car accident or if I got really sick or I needed medication,” Ramis said. “I would have to pay a lot out of pocket just to get anyone to even see me.”

Groups such as Missourians For Healthcare have poured millions of dollars into campaigns to support expansion of Medicaid coverage in the state.

The coronavirus pandemic has raised additional concerns for those who do not have insurance. With the recent spike in unemployment, tens of thousands of Missourians have found themselves without their normal income or employer-provided health insurance. And, since the onset of the pandemic in March, around 90,000 people have been added to the state’s Medicaid program.

For those who still don’t qualify for Medicaid but are suddenly without employer-provided insurance or the means to buy private insurance, the prospect of the virus looms overhead, causing them to worry what could happen if they contract it.

Knowlton knows that fear. Her husband is a full-time truck driver who spends most of his time working away from home. Since the onset of the pandemic, he has also been the sole provider for the family.

“It’s scary because I take care of the family and my husband would have to come off the road to be with our son, which would bring the family income even lower,” Knowlton said.

Knowlton is not alone in her concerns, as Ramis voices fears — and hopes — of her own.

“It’s been kind of scary,” Ramis said. “Hopefully, I’m just lucky and I don’t get it.”


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