Update (Aug. 4): Amendment 2, the initiative to expand Medicaid, has prevailed.

The opioid crisis has taken a particularly grim toll in Missouri, especially for communities of color. Two years ago, Missouri saw a 16 percent spike in fatal overdoses while the national average trended downward, and the state also has the third highest overdose rate among Black people.

On Aug. 4, Missouri voters will decide whether to expand Medicaid in a ballot initiative. If Amendment 2 passes, it would overhaul Missouri’s approach to addiction by steering more resources toward treatment programs that can counter criminalization. The expansion would also unlock billions in federal funding for health coverage and hospitals and provide coverage to an estimated 230,000 low-income adults and 40,000 children. 

In recent years, voters in a handful of red states have expanded Medicaid through ballot initiatives, overriding conservative officials who have refused to take advantage of the federal Affordable Care Act to extend health insurance to millions of residents. Last month, Oklahoma became the latest to join this trend when voters approved a referendum by 1 percentage point.

The stakes are similar across the board: Economic and racial disparities, coupled with a crisis in rural healthcare, make Medicaid expansion a life and death issue in every state that hasn’t grown the program. Now, nearly 600,000 people in Missouri have filed for unemployment insurance due to the coronavirus pandemic, which means the number of people who would benefit from Medicaid expansion could be even higher than previously thought, with outsized ramifications for anyone who would like to access programs for substance use.

The spread of illicitly manufactured fentanyl, a potent opioid, has hit Black communities in the postindustrial city of St. Louis especially hard. Last year, opioid-related deaths among Black men in St. Louis and St. Louis County increased by 17 percent, even though they dropped by 8 percent in that area overall, according to preliminary data released this week by the Centers for Disease Control and Prevention. 

“In Missouri, we have deaths of despair,” Timothy McBride, a health economist at Washington University in St. Louis, told The Appeal: Political Report. “We have rises in deaths from alcohol, drugs, and suicide—it’s not a pretty picture, and it’s not getting any better.” 

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Robert Riley II knows firsthand how Medicaid expansion could make a difference for people struggling with drug use. He spent time in prison on drug-related charges before co-founding the nonprofit Missouri Network for Opiate Reform and Recovery, otherwise known as the MoNetwork, in 2012.

“My incarceration and substance use experience are my greatest assets today,” Riley told the Political Report. “It allows me to provide empathy and guidance on staying safe to someone actively using, but most of all, I view the person suffering as a human being. And that humanity is what I feel is missing in debates about healthcare, and that’s because of stigma in America.” 

Staff at the MoNetwork drive an old ambulance around St. Louis, distributing overdose-reversal kits, sterile syringes, and other supplies to people who use drugs and are unstably housed. Since the pandemic, they’ve added hand sanitizer, gloves, and masks among the supplies they give away for free. Riley and the MoNetwork have created an oasis of compassion and non-judgement for the communities they serve. 

In addition to supplying tools to prevent overdose and exposure to HIV and hepatitis C, the MoNetwork also refers people to treatment and recovery housing. But the Covid-19 pandemic has strained budgets, limited the availability of treatment slots, and, out of precaution, some facilities stopped admitting new patients, leaving many without the care they need. 

Organizations like MoNetwork can only provide so much support with donations and charity funding. Without a well-funded safety net, they’re left putting Band-Aids on bullet wounds.

“We know that within Missouri’s safety net substance use treatment programs, about 70 percent of people who present for treatment are completely uninsured,” Rachel Winograd, associate research professor at the University of Missouri-St. Louis, told the Political Report. “Having a larger client population that has any type of insurance coverage, including Medicaid, allows programs to help more people.” Winograd said expanding Medicaid would ultimately reduce the number of uninsured people seeking help.

States that expanded Medicaid saw admissions for addiction treatment increase by 113 percent, according to a 2017 study in the Journal of Health Economics. The same study found admissions for medication treatments like methadone and buprenorphine increased by 105 percent. Both medications are considered “the gold standard” for treating opioid addiction and have shown to significantly reduce the risk of fatal overdose. A January 2020 study in the Journal of the American Medical Association found fewer overdose deaths from heroin and illicit fentanyl in states that expanded Medicaid compared to those that did not. 

“Our results suggest that Medicaid expansion might have prevented between 1,678 to 8,132 overdose deaths in the 2015 to 2017 period in the 32 states that expanded Medicaid,” Nicole Kravitz-Wirtz, the lead author of the 2020 JAMA study, told the Political Report. 

Medicaid expansion could also prevent incarceration. A high percentage of people incarcerated have a substance use disorder diagnosis and could benefit from treatment instead of going to jail. 

“If we treat substance use instead of punish people, we’ll see the number of people flowing through our criminal justice system drop. Preventive measures and treatment work better than incarceration, and it saves the state money,” Riley said.

Research cited by McBride found the same trend in other expansion states like Louisiana and Montana, which saw significant cost savings related to behavioral health and the criminal justice system.

“At the end of the day, it comes down to stigma,” Riley said. “We can talk about budgets and cost savings, but until more people have healthcare, better access to treatment, and are treated with dignity, it’ll keep being a struggle to save lives.”

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The push to expand Missouri’s public insurance through a ballot initiative is supported by groups like The Fairness Project, a nonprofit that successfully spearheaded similar campaigns in several other states. Jonathan Schleifer, executive director of The Fairness Project, said expanding Medicaid isn’t just about healthcare.

“It’s also an economic justice issue by removing one of the greatest stressors”—the cost of healthcare—“in a family’s life.” He added, “The pandemic has exposed America’s invisible workers now as ‘essential workers,’ and we’re trying to help them with Medicaid expansion.”

At the moment, Missouri has some of the strictest eligibility criteria for Medicaid in the country. Single men, single women, and married couples are not eligible regardless of their income. To be eligible for Medicaid in Missouri, one must be disabled and not working, or be a parent and earn a yearly income below 20 percent of the poverty line, which for a family of three is a paltry $4,000. 

Expanding Medicaid would drastically change who is eligible for coverage. With Amendment 2, adults ages 19 to 64 whose income is at or below 138 percent of the poverty level—which is $29,973 for a family of three—would qualify.

McBride calls the 190,000 adults who are currently left out of Medicaid in Missouri the “gap population.” He says they are working but are not offered employee health insurance and make too little to qualify for a plan from the federal Healthcare Marketplace. 

“Most of the uninsured are low-income people who have low wage jobs,” McBride, told the Political Report. “If you’re making $12,000 a year, one medical bill could kill you. One visit to the ER for $500, they can’t pay it. One drug they have to pay for is impossible.” 

Like in other states, people in Missouri are more likely to be uninsured if they live in rural areas, which is one of the main drivers behind rural hospitals shutting down across the state. 

“Many of our rural hospitals are hanging on by a thread,” Ryan Barker, the vice president of strategic initiatives at the Missouri Foundation for Health, told the Political Report. “We’ve lost 10 rural hospitals in the last six or seven years … and a lot of that is because they see a higher percentage of uninsured patients.” He added, “Hospitals are not only important access points for residents in rural Missouri, but are often the largest employers in rural areas. If you lose the hospitals, you also lose a lot of jobs.”

Roughly 45 percent of Missouri’s hospitals are located in rural areas. A study published in 2018 found that hospitals in states that expanded Medicaid were more than six times less likely to close than hospitals in non-expansion states. The effect of Medicaid expansion on hospitals was especially strong in more rural areas, where federal funding gave rural hospitals a stronger financial footing.

If Missourians vote to expand Medicaid to low-income and working people, it would become the sixth state where voters bypass Republican leaders through the ballot to expand public health coverage, after Maine in 2017, Idaho, Nebraska, and Utah in 2018, and Oklahoma last month.

A “yes” vote for Amendment 2 would write Medicaid expansion into Missouri’s constitution, limiting the possibility for Republican leaders to block implementation or add stricter eligibility burdens like work requirements. 

In 2017, voters in Maine, another state hit hard by overdose deaths, approved Medicaid expansion, but then-Governor Paul LePage refused to implement the program. The expansion wasn’t enacted until January 2019, after LePage lost his re-election bid to Janet Mills, a Democrat, who ordered the results of the referendum to stand. Mills cited the urgency of the opioid crisis in Maine and a lack of treatment capacity as some of the primary reasons to expand Medicaid. 

“Americans in even the reddest of states want healthcare, and they’re willing to put it in their constitution to protect it from political meddling,” Schleifer told the Political Report. “That’s why we put expansion on the ballot for the people to decide. We’re talking about life and death differences in expansion versus non-expansion states.”

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Cook County, Illinois: State’s Attorney Kim Foxx announced a shift to treating drug possession writ large (beyond marijuana cases) as a public health matter, with a default of no incarceration. “Incarceration is not treatment, and the Cook County State’s Attorney’s office will no longer address the public health crisis of drug addiction in our criminal justice system,” she said in a Jan. 24 speech. “Diversion will be the presumption in drug possession cases.” In the same speech, Foxx launched a program to “pursue the expungement of all misdemeanor marijuana convictions.” What this means according to the Chicago Citizen is that people will be able to apply for expungement with her office’s assistance without paying an expungement fee, instead of going through the existing process that requires a payment. “Failing to take action that provides relief to those who already have a marijuana conviction is not justice,” she said. Illinois lawmakers are mulling legalizing marijuana, and advocates are pushing for such legislation to contain an automatic expungement process.

Baltimore City, Maryland: Marilyn Mosby, the Baltimore state’s attorney, announced on Jan. 29 that her office would no longer prosecute marijuana possession no matter the quantity. She also said that she would act to vacate thousands of old convictions. In a 14-page white paper, her office laid out her rationale, detailing the “crisis of disparate treatment of Black people for marijuana possession and other offenses without any seeming regard for the possible adverse public health effects resulting from such enforcement.” Interim police commissioner Gary Tuggle said he will still arrest people. “If you are arrested for having and being in possession of a marijuana you will then be released without charges,” Mosby told NPR in response.

St. Louis County, Missouri: St. Louis County’s new prosecutor, Wesley Bell, issued a policy of no longer prosecuting the possession of under 100 grams of marijuana; he will still prosecute larger quantities if he is also accusing a defendant of an intent to sell. Bell’s decision echoes that announced in June by Kim Gardner, the chief prosecutor of the city of St. Louis.

One outstanding question is the persistence of modes of enforcement besides prosecution. In these Missouri jurisdictions, municipal officials can still issue citations that remain on one’s record and result in fines; this has limited the impact of local steps toward decriminalization in the past. When St. Louis made the possession of less than 35 grams of marijuana into an offense for which the police should issue citations in 2014, this has made no dent in the racial disparities in police enforcement. According to the Riverfont Times, 85 percent of people who were either arrested or issued a citation in the ensuing years were Black. This mirrors Baltimore’s past dynamics. In 2014, Maryland as a whole decriminalized the act of possessing under 10 grams of marijuana. But Black residents received 94 percent of the marijuana citations subsequently issued by the Baltimore Police Department between 2015 and 2017, according to the white paper from Mosby’s office; that is virtually identical to the share of people charged with misdemeanor marijuana possession in Baltimore during that period who were Black (96 percent).

Scott Hechinger, senior staff attorney and director of policy at Brooklyn Defender Services, warned more broadly that, absent legalization, marijuana will remain a pretext for heavy-handed policing. “The larger issue is that as long as marijuana is a crime on the books, it will be used by law enforcement as a justification to hurt people,” he said. “Marijuana is one of the primary justifications that allows law enforcement to approach, stop-and-frisk our clients. The claimed odor of marijuana is what makes already-pretextual car stops into full-blown car searches.”

Another matter for continued scrutiny is the manner in which prosecutors will implement their own stated policies. Raven Rakia reported in The Appeal in November that the Brooklyn district attorney, who had announced he would stop prosecuting most marijuana possession cases, was still prosecuting people caught with vaping marijuana oil.

Hechinger, who works in Brooklyn, said that one issue is the mismatch between rhetoric and practices on the ground, but also that prosecutors often leave “exceptions and carve-outs” in their decline-to-prosecute policies such as the amount possessed, whether the person stopped has a record, and the form of possession. If the reason prosecutors adopt decline-to-prosecute policies is the “known disproportionate law enforcement impact on communities of color,” Hechinger said, then it shouldn’t matter who you are and how much you have” because “these carve-outs tend to replicate pre-existing racial disparities” in the prosecution of marijuana possession. “It’s worth always questioning the rationales behind the carve-outs,” he added.

The post Prosecutors Announce New Marijuana Policy in Illinois, Maryland, and Missouri appeared first on Bolts.

Last week, I talked to Reverend Dr. Cassandra Gould, the executive director of Missouri Faith Voices, about her work in St. Louis and about what toppled the longtime prosecutor. 

The interview has been lightly edited and condensed.

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How were you involved in the Ferguson protests and in this year’s election for prosecutor?

I’ve lived in the St. Louis area for more than 35 years. When Ferguson happened, I was there between August and the non-indictment [of Darren Wilson] on Nov. 24. I stayed a minimum 75 nights in the street, as a person who was part of the community. It was a situation where all hands had to be in deck. I became officially employed by Faith Voices in 2015.

I was very fueled by the events of Ferguson. Literally on the night of the non-indictment my prayer was I would have an opportunity to be directly involved four years later in changing history. Everybody figured Bob McCulloch would stay in office forever, more in less. Last year, we decided that this prosecutor race would be the biggest thing that we would work on this year. We held our first meeting on the role of the prosecutor training in 2017 so that ordinary citizens could understand how their lives are affected. We saw this race as being very pivotal in restoring hope to the community and in changing the course of history.

Bob McCulloch had been in office since 1991. What do you think made his loss possible in 2018 when he’d been winning for so long?

In 2016, there were [local] elections in Ferguson. It resulted in the same leadership that was already there prior to the murder of Michael Brown. One of the things that I realized was that despite the fact that there were grassroots organizations that were there for years, no one was actually coordinating organizing in the African American community specifically around criminal justice reform. In the city there were organizations working on police reform neighborhood policing for years, but in St. Louis County no one was specifically coordinating the organizing, particularly in African American communities. Our bet was that if we focus specifically on increasing the electorate by having conversations with voters of color and Black voters who don’t normally vote, we could increase turnout, and not just for the sake of one election. People could start taking ownership of their own community.

We were knocking on doors and talking to young people, particularly in Ferguson, and asking them what they wanted to be different. We discovered that there was a sense of hopelessness in the situation. They felt that the system was completely against them and that they didn’t have an opportunity to change it. But we talked to people and we listened; people really started to come on board and to re-imagine what their community could look like.

We made this big bet to do something different. Most campaigns focus on white swing voters, but we decided we wanted this to be the people’s campaign. We hired people who understood the criminal justice system. We had a young man run our canvassing campaign who was a formerly incarcerated person. We wanted people who had a stake in the game and understood the criminal justice system from the inside out.

How receptive did you find your audience to be, compared to in the past?

This receptiveness was not there before. It wasn’t there before at all, particularly in the St. Louis metropolitan area, when you go against this Democratic icon. It’s more than just a political trend, it really means that the people actually spoke, and the people started to work toward their own liberation. We had honest conversation that centered on the criminal justice system and the implications that race and racism have in the criminal justice system, and this really resonated with people. What we saw was people who didn’t come out before and thought whatever would happen would happen. We never actually endorsed Wesley Bell, we gave the people the information that they needed so that they could make informed decisions, and empower them to use their voice in the ballot box.

How did you collaborate with other organizations as part of this work?

Locally we coordinated specifically with the St. Louis Action Council, run by Kayla Reed, an activist who I met in the streets of Ferguson. And Color of Change, they were on the ground in Ferguson as well. The three of us, three organizations, Color of Change, Action St. Louis, and Missouri Faith Voices, we had one of our offices together in Ferguson, and that meant that we were dividing up turf, that meant that we were using different tactics and more people had opportunity to be reached. The three of us specifically focused on African American voters. Other organizations’ message was not the same because their audience was not the same.

We talked a lot about Mike Brown and murder with impunity, and how a system that has white supremacy as a cornerstone continues to ensure that African Americans will rarely get justice in a system like that. We’ll be dealt with unfairly in a system that has a cornerstone of white supremacy. We tied that with cash bail and high fees and fines, and we tied that with what it would mean to the African American community if things stayed the same.

What were the main messages you heard in your conversations during the campaign?

Particularly among young African Americans, it was about feeling harassed. I would say 98% of the people we talked to they had some personal involvement with police, with traffic stops, with fines and fees, or if it wasn’t them it was some family member who was impacted by the system in very negative ways. We heard a lot about the amount of time they spent in jail waiting for a hearing or trial.

Some people don’t know that, they don’t know what happens behind the curtain. Having people share those stories in public spaces made a tremendous difference. It was extremely eye-opening for [an all-white congregation at an event in the Eliot Chapel in Kirkwood, Missouri] to have people from the African American community share their stories about how they were impacted by the criminal justice system. It was a very different audience, but them listening to the stories of people who were impacted also had an indelible effect in them in how they saw the prosecutor and the role of the prosecutor.

People who are impacted know it’s not just their stories. But rarely do they get to tell their story, and rarely do people care enough to listen to their story, and many of them are not accustomed to the power of their story. Using their voice and engaging in a democratic process, it’s also a way to lift their voice. We were able to connect the story of their pain to their opportunity to make something different happen, as opposed to keeping it to yourself but not ever bringing it to light.

What are some specific expectations you have now of Wesley Bell, and what do you think is the role of organizing going forward?

I would say that Wesley Bell’s camp cares enough about grassroots to stay connected by having a liaison to transition; grassroots organizations have met with the Wesley Bell Campaign almost monthly since he got elected. We expect that some things won’t change overnight. We do expect some sentencing changes, we expect diversions, so particularly in nonviolent cases instead of jail and cash fines and fees people would be able to have some alternatives to that. One of our goals in the next 18 months is to really work on eliminating cash bail in the state of Missouri, using the St. Louis area as a test case of that. We expect that Wesley Bell will lead the way,bail.

We want to have an ongoing relationship with the prosecutor’s office. We don’t want a staff position, but we want to be in conversation with him, and remind him of the pain of the people, remind him of why it was necessary to elect him so that things don’t stay the same. We don’t expect St. Louis County to be run the same way in two years that it was run over the past 27 years. We believe that ongoing engagement and commitment with the prosecutor’s office is extremely important.

I also believe that, even beyond the prosecutor in St. Louis County, we put elected officials on notice that the power still rests with the people. We believe this puts elected officials on notice that the people will have the last word, and they can no longer expect for the people to sit by and allow things to happen to them. We know that there is an awful lot of work to do, but we are also excited about the opportunities, especially as it pertains to the historical fight for African Americans in Missouri and around the country. We really want to be a model for change.

I want to say that I want to say we are a multifaith, multiracial organization, and one of the questions we ask our members was, What does your faith say about a justice system that is punitive for one race of people or one class of people? We approached it with our faith leading the way, and we had people in Springfield, and Columbia, which are hundreds of miles away, but participated in this prosecutor race whether it was phone-banking or other ways. It was a pivotal moment. It was a shared decision that this was the most important engagement this year. We made the case that this is about the liberation of all of us in that state, it was everybody’s fight.

The post How Activists Helped Change St. Louis: An Interview with Cassandra Gould appeared first on Bolts.