That was all set to change on July 1 because of a constitutional amendment voters approved last summer, which made Missouri the 38th state to expand Medicaid coverage through the Affordable Care Act. Single adults would be covered if they made under around $17,770.

As many as could get coverage — if there’s funding for the program. But in the deep-red state, which voted for former President Donald Trump by more than 15 percentage points in 2020, lawmakers are looking to undo the voters’ decision.

As it crafts the budget for the next fiscal year, the state legislature has moved to strip funding for Medicaid expansion. Rep. Cody Smith, the Republican chair of the House budget committee, separated the money for expansion into its own bill, which the GOP-controlled committee voted down in March. On the floor of the House last week, Smith said, “Medicaid expansion is wrong for Missouri, I think it’s wrong for the state budget.”

Smith argued spending on expansion is irresponsible, even though the federal government covers 90% of the costs for those covered under expansion. Compare that with the 60% of costs Washington covers for current Medicaid recipients.

Nevertheless, Smith contended that “the federal government has no money — there is only taxpayer dollars. They are federal-deficit-spending at a rate that is unprecedented at this point.”

Complicating that argument is the state’s current budget surplus, which Missouri’s Republican governor for the 2021 fiscal year. In addition to an influx in federal aid money, the state saw higher-than-expected revenues and, because it delayed tax collection in 2020, that money rolled over into the current fiscal year, which began in July 2020.

Some Republicans contend the rural districts they represent voted against the measure; others claim voters were misled. For example, during floor debate on the budget last week, Republican Rep. Justin Hill said, “Even though my constituents voted for this lie, I am going to protect them from this lie.”

Democrats argue Republicans are pushing ideology over the will of the people — who voted by more than 6 percentage points to expand the program. They also contend the legislature is now required to fund expansion because it’s in the constitution.

“Even if we didn’t have a surplus right now of dollars, we’ve seen in every other state that’s expanded they’ve actually had cost savings in states and revenue increases,” said Rep. Peter Merideth, the ranking Democrat on the House budget committee.

A has found a range of budget benefits associated with Medicaid expansion, and opponents’ predictions that paying for expansion comes at a cost for other priorities such as education or transportation have not proved true for other states.

Additionally, the American Rescue Plan Act, which President Joe Biden signed into law last month, compels the federal government to pitch in an extra 5% of costs for new expansion states.

In Missouri, that could amount to $1 billion over the next two years, . That incentive has pushed other GOP-controlled states to consider expanding Medicaid as well, and Missouri Republican Gov. Mike Parson included expansion funding in his proposed budget. While Parson opposed expansion in the run-up to the vote, he has since argued he has to carry out the will of the voters. “If it’s not funded, there’ll be challenges to that,” Parson said at a recent press briefing.

There are a number of ways those legal challenges could play out. Thomas Bennett, an associate professor at the University of Missouri School of Law, said it will depend on what the state Department of Social Services does with the money it is budgeted.

If the state denied coverage to someone eligible under expansion, Bennett said, that would be grounds for a lawsuit. On the other hand, Missouri “could just try to muddle through with the money that it already has and try to provide as much coverage as it could to everybody who is made eligible.” That, Bennett said, could result in another set of problems, because there are minimum standards the state must meet to participate in Medicaid.

James Layton, a former solicitor general for Missouri, points to more trouble the legislature could run into with the Missouri Constitution. The ballot measure was a constitutional amendment, Layton explained. “The legislature can’t actually change eligibility for MO HealthNet in an appropriations bill,” Layton said. “This particular aspect of Medicaid eligibility — of MO HealthNet eligibility — it’s in the constitution, so the legislature can’t change it at all.”

The big legal question of what happens if the legislature defies the constitutional amendment could still be rendered moot. The budget will now head to the state Senate, where Republicans are split over what to do. While some have said they support including expansion funding, others are still speaking out against it. The deadline for those disputes to be resolved is July 1, the date the constitution states eligibility will expand, regardless of funding.

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He did not.

What he got instead from those town halls last month was encouragement to return to class at the institution affectionately known as Mizzou. The university, in Columbia, would be testing only people with symptoms, and at that point, the university said people who test positive off campus to inform the school.

“It feels like the university doesn’t really care whether we get sick or not,” said El-Jayyousi, who is scheduled for two in-person classes, and lives at home with his parents and 90-year-old grandmother.

He’s seen the studies from researchers at Yale and Harvard that suggest testing needs to be much more widespread. He asked his instructors if he could join lectures remotely once classes begin Monday. One was considering it; the other rejected it.

“It was kind of very dismissive, like ‘so what?’” El-Jayyousi said.

But it’s an enormous “so what?” packed with fear and unknowns for Jayyousi and some 20 million other students enrolled in some level of postsecondary education in America, if they are not already online only.

As with the uncoordinated and chaotic national response to the COVID-19 pandemic, higher education has no clear guidance or set of standards to adhere to from the federal government or anywhere else. Policies for reentry onto campuses that were abruptly shut in March are all over the map.

Hundreds Undecided

According to the , or C2i, a project of Davidson College that monitors how higher ed is responding to the pandemic, there is nothing resembling a common approach. Of 2,958 institutions it follows, 151 were planning to open fully online, 729 were mostly online and 433 were taking a hybrid approach. Just 75 schools were insisting on students attending fully in person, and 614 were aiming to be primarily in-person. Some 800 others were still deciding, just weeks before instruction was to start.

The decisions often have little correlation with the public health advisories in the region. Mizzou, which is in an area with recent COVID spikes, is holding some in-person instruction and has nearly 7,000 students signed up to live in dorms and other university-owned housing. Harvard, in a region with extremely low rates of viral spread, has opted to go all online and allowed students to defer a year.

The specific circumstances colleges and universities face are as much determined by local fiscal and political dictates as by medicine and epidemiology. It is often unclear who is making the call. So it’s every-student-for-herself to chart these unknown waters, even as students (or their families) have written tuition checks for tens of thousands of dollars and signed leases for campus and off-campus housing.

And the risks — health, educational and financial — boomerang back on individual students: Two weeks after University of North Carolina students, as instructed, returned to the flagship campus in Chapel Hill with the promise of at least some in-person learning, all classes went online. Early outbreaks surged from a few students to more than 130 in a matter of days. Most undergrads have about a week to clear out of their dorms.

“It’s really tough,” said neuroscience major Luke Lawless, 20. “Chapel Hill is an amazing place, and as a senior it’s tough to know that my time’s running out — and the virus only adds to that.”

Location, Location, Location

C2i’s creator, Davidson education Assistant Professor , said the extreme diversity of approaches comes from the sheer diversity of schools, the penchant of many to follow the leads of more prestigious peers, and local politics.

“Some states have very strong and stringent mask requirements. Some have stronger stay-at-home orders. Others are sort of leaving it up to localities. So the confluence of politics, institutional isomorphism — that imitation — and different needs that the institutions have are driving the differences,” Marsicano said.

Location matters a lot, too, Marsicano said, pointing to schools like George Washington University and Boston University in urban settings where the environment is beyond the control of the school, versus a place like the University of the South in remote, rural Sewanee, Tennessee, where 90% of students will return to campus.

“It’s a lot easier to control an outbreak if you are a fairly isolated college campus than if you are in the middle of a city,” Marsicano said.

Student behavior is another wild card, Marsicano said, since even the best plans will fail if college kids “do something stupid, like have a massive frat party without masks.”

“You’ve got student affairs professionals across the country who are screaming at the top of their lungs, ‘We can’t control student behavior when they go off campus’” Marsicano said.

Another factor is a vacuum at the federal level. Although the Department of Education says Secretary Betsy DeVos has held dozens of calls with governors and state education superintendents, there’s no sign of an attempt to offer unified guidance to colleges beyond that links to relaxed regulatory requirements and anodyne fact sheets from the Centers for Disease Control and Prevention on preventing viral spread.

Even the money that the department notes it has dispensed — $30 billion from Congress’ CARES Act — is weighted toward K-12 schools, with about $13 billion for higher education, including student aid.

The U.S. Senate adjourned last week until Sept. 8, having never taken up a House-passed relief package that included some $30 billion for higher education. A trio of Democratic senators, including Sen. Elizabeth Warren, standards on college campuses.

No Benchmarks

Campus communities with very different levels of contagion are making opposite calls about in-person learning. Mizzou’s Boone County has seen more than 1,400 confirmed COVID cases after a spike in mid-July. According to the Harvard Global Health Institute’s COVID risk map, Boone has accelerated spread, with 14 infections per day per 100,000 people. The institute advises stay-at-home orders or rigorous testing and tracing at such rates of infection. Two neighboring counties were in the red zone recently, with more than 25 cases per day per 100,000 people. Mizzou has left it up to deans whether classes will meet in person, making a strong argument for face-to-face instruction.

Meanwhile, Columbia University in New York City opted for all online instruction, even though the rate of infection there is a comparatively low 3.8 cases per day per 100,000 people.

Administrators at Mizzou considered and rejected mandatory testing. “All that does is provide one a snapshot of the situation,” University of Missouri system President Mun Choi said in one of the town halls.

Mizzou has an in-house team that will carry out case investigation and contact tracing with the local health department. This week, following questions from the press and pressure from the public, the university announced any positive COVID test to the school.

Who Do You Test? When?

CDC guidance for higher education suggests there’s not enough data to know whether testing everyone is effective, but some influential researchers, such as those at Harvard and Yale, disagree.

“This virus is subject to silent spreading and asymptomatic spreading, and it’s very hard to play catch-up,” said Yale professor , who studies public health policy. “And so thinking that you can keep your campus safe by simply waiting until students develop symptoms before acting, I think, is a very dangerous game.”

conducted by Paltiel and his colleagues show that, of all the factors university administrators can control — including the sensitivity and specificity of COVID-19 tests — the frequency of testing is most important.

He’s “painfully aware” that testing everyone on campus every few days sets a very high bar — logistically, financially, behaviorally — that may be beyond what most schools can reach. But he says the consequences of reopening campuses without those measures are severe, not just for students, but for vulnerable populations among school workers and in the surrounding community.

“You really have to ask yourself whether you have any business reopening if you’re not going to commit to an aggressive program of high-frequency testing,” he said.

The Fighting — And Testing — Illini

Some institutions that desperately want students to return to campus are backing the goal with a maximal approach to safety and testing.

About a four-hour drive east along the interstates from Mizzou is the University of Illinois at Urbana-Champaign, whose sports teams are known as the Fighting Illini.

Weeks ago, large white tents with signs reading “Walk-Up COVID-19 Testing” have popped up across campus; there students take a simple saliva test.

“This seems to be a lot easier than sticking a cotton swab up your nose,” graduate student Kristen Muñoz said after collecting a bit of her saliva in a plastic tube and sealing it in a bag labeled “Biohazard.”

In just a few hours, she got back her result: negative.

The school plans to offer free tests to the 50,000 students expected to return this month, as well as some 11,000 faculty and staff members.

“The exciting thing is, because we can test up to 10,000 per day, it allows the scientist to do what’s really the best for trying to protect the community as opposed to having to cut corners, because of the limitations of the testing,” said University of Illinois chemist , who helped develop the , which received emergency use authorization from the federal Food and Drug Administration this week.

The test is similar to one designed by Yale and funded by the NBA that cleared the FDA hurdle just before the Illinois test. Both Yale and Illinois hope aggressive testing will allow most undergraduate students to live on campus, even though most classes will be online.

University of Illinois epidemiologist said they are following data that suggest campuses need to test everyone every few days because the virus is not detectable in infected people for three or four days.

“But about two days after that, your infectiousness peaks,” she said. “So, we have a very small window of time in which to catch people before they have done most of the infection that they’re going to be doing.”

Campus officials accepted Smith’s recommendation that all faculty, staffers and students participating in any on-campus activities be required to get tested twice a week.

Illinois can do that because its test is convenient and not invasive, which spares the campus from using as much personal protective equipment as the more invasive tests require, Burke said. And on-site analysis avoids backlogs at public health and commercial labs.

Muddled in the Middle

Most other colleges fall somewhere between the approaches of Mizzou and the University of Illinois, and many of their students still are uncertain how their fall semester will go.

At the University of Southern California, a private campus of about 48,500 students in Los Angeles, officials had hoped to have about 20% of classes in person — but the county government , insisting on for reopening than the statewide standards.

If students eventually are allowed back, they will have to show a recent coronavirus test result that they obtained on their own, said Dr. Sarah Van Orman, chief health officer of USC Student Health.

They will be asked to do daily health assessments, such as fever checks, and those who have been exposed to the virus or show symptoms will receive a rapid test, with about a 24-hour turnaround through the university medical center’s lab. “We believe it is really important to have very rapid access to those results,” Van Orman said.

At California State University — the nation’s largest four-year system, with 23 campuses and nearly a half-million students — officials decided to move nearly all its fall courses online.

“The first priority was really the health and safety of all of the campus community,” said Mike Uhlenkamp, spokesperson for the CSU Chancellor’s Office. About 10% of CSU students are expected to attend some in-person classes, such as nursing lab courses, fine art and dance classes, and some graduate classes.

Uhlenkamp said testing protocols are being left up to each campus, though all are required to follow local safety guidelines. And without a medical campus in the system, CSU campuses do not have the same capacity to take charge of their own testing, as the University of Illinois is doing.

For students who know they won’t be on campus this fall, there is regret at lost social experiences, networking and hands-on learning so important to college.

But the certainty also brings relief.

“I don’t think I would want to be indoors with a group of, you know, even just a handful of people, even if we have masks on,” said Haley Gray, a 28-year-old graduate student at the University of California-Berkeley starting the second year of her journalism program.

She knows she won’t have access to Berkeley’s advanced media labs or the collaborative sessions students experience there. And she said she realized the other day she probably won’t just sit around the student lounge and strike up unexpected friendships.

“That’s a pretty big bummer but, you know, I think overall we’re all just doing our best, and given the circumstances, I feel pretty OK about it,” she said.

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Utiliza la estación principalmente para transmitir sermones y música religiosa. Pero en estos días también está enfocado en COVID-19: explicar la enfermedad y sus síntomas, actualizar a sus oyentes sobre las cifras de casos más recientes, y atraer invitados. Ha realizado con una enfermera local y con investigadores de los Centros para el Control y Prevención de Enfermedades (CDC).

Bonilla y algunos compañeros pastores han cerrado sus iglesias en medio de la pandemia. Pero hay unas 30 iglesias que sirven a la comunidad latina de la ciudad, y dijo que otros pastores no han actuado con tanta responsabilidad.

Explicó que algunos líderes religiosos pueden creer que no celebrar servicios significa que no tienen fe, y quieren demostrar que Dios tiene el control.

Desde junio, el suroeste de Missouri ha experimentado un aumento de casos de coronavirus, incluido un brote entre los trabajadores de la planta de procesamiento de aves Butterball, en Carthage. Las infecciones por coronavirus han sido un problema en las plantas procesadoras en muchos estados. El impacto ha sido particularmente duro en las comunidades latinas, que a menudo proporcionan la mayor parte de la fuerza laboral de las plantas.

Los hispanos se han visto afectados de manera desproporcionada por COVID-19. A nivel nacional, los pacientes hispanos son hospitalizados por COVID-19 a que la de los blancos no hispanos. (Los hispanos pueden ser de cualquier raza o combinación de razas).

En Missouri, los hispanos y latinos representan el 4% de la población del estado, pero el . En el condado de Jasper, donde se encuentra Carthage, representan casi el 40% de los casos confirmados, pero solo el 8,5% de la población, según el Departamento de Salud y Servicios para Adultos Mayores de Missouri.

Muchos inmigrantes latinoamericanos llegaron a Carthage en las últimas décadas, para trabajar en la planta de Butterball, que emplea a cerca de 800 personas en una ciudad de aproximadamente 15,000 habitantes. Los primeros eran predominantemente de México. Pero los que se mudaron al área en los últimas veinte años vinieron principalmente de Guatemala y El Salvador.

La planta de Butterball está a 800 metros del centro cívico de la ciudad de Carthage, en línea recta hacia el norte por Main Street. En ese tramo hay pequeñas tiendas y restaurantes, muchos con volantes en español en las ventanas. Anuncian servicios de envíos de dinero, libros de autoayuda y disponibilidad de productos originales de Guatemala y El Salvador.

La planta de Butterball siempre ha sido una especie de ancla para el concejal de Carthage, Juan Topete. Sus padres mexicoamericanos trabajaron allí en la década de los 90, después de mudarse con la familia desde Los Ángeles. Cuando era más joven, Topete también trabajó para Butterball.

“Mi familia pasó de no tener nada, solo lo que teníamos en nuestro U-Haul, a ser dueños de un restaurant, que luego vendimos, y estar bien establecidos en la comunidad”, explicó Topete.

Es una historia común para muchos de los inmigrantes latinoamericanos en Carthage, quienes pueden encontrar trabajos bien pagos en la planta sin tener que hablar inglés.

“Cuando me mudé aquí por primera vez, los hispanos se conocían entre ellos”, dijo Topete. “Era un grupo muy unido, y se ha expandido enormemente en estos últimos años”.

En estos días, un tercio de la población de Carthage es hispana, según la Oficina del Censo de los Estados Unidos. En 2016, Topete ganó un asiento en el Concejo Municipal, el primer residente latino electo.

Topete dijo que los residentes latinos en Butterball y en otros trabajos esenciales enfrentan presiones en varios frentes. Algunos que dan positivo para el coronavirus sienten que tienen que seguir trabajando. Tienen miedo que los despidan o necesitan el dinero para sus familias.

“Conozco personas que dieron positivo”, dijo Topete. “Trato de mantenerme en contacto llamándolos, haciendo un seguimiento, asegurándome de que estén bien”.

Un equipo de los CDC visitó Carthage para investigar el brote. Informaron que el virus llegó a la planta de Butterball, infectando a los trabajadores y propagándose a través de sus familias. En un comunicado, Butterball confirmó que había casos positivos, pero se negó a decir cuántos.

Topete dijo que algunos residentes aún no saben mucho sobre la enfermedad, por lo que la ciudad está aumentando su alcance.

Un producido por el Departamento de Policía de Carthage explica que el levantamiento por parte del gobernador de Missouri de la orden estatal de quedarse en casa no significa que el virus haya desaparecido. El Departamento de Policía es parte del grupo de trabajo de COVID-19 de la ciudad y ha ayudado a Topete a publicar volantes en español.

Los departamentos de salud rurales enfrentan obstáculos para conectarse con las comunidades de inmigrantes, dijo Lori Freeman, directora ejecutiva de la . Por lo general, tienen menos recursos lingüísticos que sus contrapartes urbanos más grandes, dijo.

“En los departamentos de salud más grandes o incluso medianos, hay trabajadores de salud comunitarios que a menudo son lo suficientemente bilingües o fluidos en el idioma para servir a las comunidades en sus áreas demográficas”, agregó Freeman.

En La Tiendita Mexican Market, un mercado y restaurante, su propietario José Alvarado ha tomado medidas para ayudar a mantener seguros a sus trabajadores y clientes. Le preocupa que los niños se expongan al virus cuando sus padres los traen a la tienda, por lo que ha colocado un cartel en la puerta pidiendo que solo entre un miembro de la familia a la vez. Junto a la máquina para hacer tortillas, ha marcado el piso con grandes X, como guía visual y recordatorio para que los clientes se mantengan socialmente distantes unos de otros.

Topete teme que la comunidad latina de la ciudad se convierta en un chivo expiatorio del virus. Dijo que mucha gente tiene la impresión de que el virus sólo ha afectado a los trabajadores de la planta Butterball, cuando en realidad se ha extendido por toda la ciudad.

Topete dijo que los funcionarios de Carthage deben mantener sus esfuerzos de alcance comunitario, porque observa que los esfuerzos educativos funcionan: cuando fue a la tienda hace poco, notó que más clientes latinos estaban usando máscaras, más aún que los clientes que no eran hispanos.

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He mainly uses the station to broadcast sermons and religious music. But these days he is also focused on COVID-19: explaining the illness and its symptoms, updating his listeners with the newest case counts and bringing on guests. He has broadcast with a local nurse and with investigators from the Centers for Disease Control and Prevention.

Bonilla and some fellow pastors have closed their churches amid the pandemic. But there are some 30 churches serving the town’s Latino community, and he said other pastors haven’t acted as responsibly. Bonilla said some church leaders may believe that not holding services means they don’t have faith and that they want to show God is in control.

Starting in June, the southwestern corner of Missouri experienced a surge of coronavirus cases, including an outbreak among workers at the Butterball poultry-processing plant in Carthage. Coronavirus infections have been a problem at food-processing plants in many states. The impact has been particularly hard on nearby Latino communities, which often provide the bulk of the workforce at the plants.

Hispanics have been disproportionately affected by COVID-19. Nationwide, Hispanic patients are hospitalized for COVID-19 at of non-Hispanic whites. (Hispanics can be of any race or combination of races.)

In Missouri, Hispanics and Latinos make up 4% of the state’s population but in which race or ethnicity is known. In Jasper County, where Carthage is located, they account for almost 40% of the confirmed cases but only 8.5% of the population, according to the Missouri Department of Health and Senior Services.

Many Latin American immigrants came to Carthage to work at the Butterball plant, which employs roughly 800 people in the town of about 15,000. The first to arrive in Carthage were predominantly from Mexico. But those who moved to the area over the past two decades came primarily from Guatemala and El Salvador.

The Butterball plant is half a mile from Carthage’s town square, a straight shot north along Main Street. Along the stretch are small shops and restaurants, many with Spanish-language flyers in the windows. They advertise money transfer services, self-help books and the availability of regional ingredients from Guatemala and El Salvador.

The Butterball plant has always been a sort of anchor for Carthage Councilman Juan Topete. His Mexican American parents worked there in the 1990s, after moving the family to Carthage from Los Angeles. When he was younger, Topete also worked for Butterball.

“My family came from having nothing, whatever we had in our U-Haul and that was it, to owning a restaurant and selling it later and being well established in the community,” Topete explained.

It’s a common story for many of the Latin American immigrants to Carthage, who can find well-paying jobs at the plant without having to speak English.

“When I first moved down here, if you were Hispanic you knew each other,” Topete said. “It was a very tight group and it has expanded tremendously these last few years.”

These days, a third of the people in Carthage are Hispanic, according to the U.S. Census Bureau. In 2016, Topete won a seat on the City Council, the first Latino resident to do so.

Topete said the Latino residents at Butterball and in other essential jobs face pressure on several fronts. Some who test positive for the coronavirus feel they have to keep going to work. They’re afraid of being laid off, or they need the money for their families.

“I do know people that have tested positive,” Topete said. “I try to stay in contact by calling them, following up on them, making sure they’re doing OK.”

A CDC team visited Carthage to investigate the outbreak. They reported the virus made its way into the Butterball plant, infecting workers and spreading through their families. In a statement, Butterball confirmed workers have tested positive but declined to say how many.

Topete said some residents still don’t know much about the disease, so the city is ramping up its outreach.

A Spanish-language produced by the Carthage Police Department explains that the Missouri governor’s lifting of the statewide stay-at-home order doesn’t mean the virus is gone. The police department is part of the town’s COVID-19 task force and has helped Topete post Spanish-language flyers.

Such rural health departments face hurdles connecting to immigrant communities, said Lori Freeman, CEO of the . They typically have fewer language resources than their larger, urban counterparts, she said.

“In larger or even medium health departments, there are community health workers that are often bilingual or lingual enough to serve the communities that exist in the demographic area that they serve,” Freeman said.

At La Tiendita Mexican Market, a grocery store and restaurant, owner Jose Alvarado has taken steps to help keep his workers and customers safe. He’s concerned about children being exposed to the virus when their parents bring them in to shop, so he has posted a sign on the door asking that only one member of a family enter at a time. Next to the industrial tortilla maker, he has marked the floor with large X’s, as a visual guide and reminder for customers to stay socially distant from one another.

Topete fears the town’s Latino community could become a scapegoat for the virus. He said many people have the impression that the virus has affected only workers at the Butterball plant, when in reality it has spread throughout town.

Topete said Carthage officials need to keep up their outreach efforts but he sees the educational efforts working: On a recent trip to the store, he noticed more Latino shoppers than before wearing masks — and more of them were wearing masks than were the non-Hispanic shoppers.

This story is part of a partnership that includes , and Kaiser Health News.

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