Being Low-Income and Uninsured in Missouri: Coverage Challenges during Year One of ACA Implementation
Background: ACA Implementation in Missouri
In 2013, the last year before open enrollment, 5,001,000 non-elderly adults lived in Missouri, 12% of whom were uninsured.1 Although this rate was below the national average, Missouri faces disparities in health insurance and access to care. One in three people in Missouri live in a primary care health professional shortage area. About a third (37%) of the Missouri population lives in a rural setting, where poverty rates are higher than in cities, and many do not have access to employer sponsored coverage. In addition, a large percentage of the uninsured in Missouri live in St. Louis and Kansas City, the two largest cities in the state.2 In 2014, the St. Louis area was the setting for protests and riots following the shooting death of unarmed teenager Michael Brown. Along with many other important issues, these protests have brought attention to the economic disparities existing in these communities and the consequences of these disparities, which include the health and well-being of their residents.3
Medicaid and the Safety Net
MO HealthNet, Missouri’s Medicaid program, currently provides coverage to low-income children, some of their parents, pregnant women, the elderly, and individuals with disabilities. Prior to the ACA, all states expanded eligibility levels for children to levels beyond that for adults. In Missouri, children with family incomes up to 305% of poverty (about $60,400 for a family of three in 2014) are eligible for coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Eligibility for adults is limited to those with dependent children with incomes below 23% of poverty (about $4,600 for a family of three in 2014), one of the lowest eligibility levels in the nation. The Medicaid eligibility level for adults has remained low since 2005, when Missouri lowered eligibility levels amidst great debate in response to an economically-driven budget shortfall.4 Non-disabled adults without dependent children remain ineligible for Medicaid at any level. As in all states, regardless of whether or not they have expanded Medicaid, undocumented immigrants are ineligible for Medicaid under federal rules. The state did enact the option to cover income-eligible pregnant women regardless of immigration status through CHIP’s unborn child option, called “Show-Me Healthy Babies,” though this program was not implemented as of April 2015.
The uninsured in Missouri continue to rely on safety-net services when they need care. Most notably, the city and county of St. Louis provide funding to health centers and clinics through an 1115 Medicaid waiver, known as Gateway to Better Health. Through the waiver, uninsured nonelderly adults who live within the City and County limits, and who are not eligible for Medicaid, Medicare, or the Marketplace, are able to access primary and specialty care.5
ACA Medicaid Expansion and the Marketplace
Although the ACA envisioned providing insurance to the low-income population through Medicaid expansion, the Supreme Court’s ruling in June 2012 effectively made this optional to the states. Missouri has not expanded its MO HealthNet program under the ACA. Governor Jay Nixon supports the expansion, but faces opposition in the Missouri General Assembly, where a number of legislators oppose any form of expansion. Opposition arguments have centered on reforming Medicaid before expanding it and lack of trust that the Federal government would provide funding at the levels promised.6 However, many in the state continue to advocate for expansion, including the Missouri Hospital Association. Arguments in favor of expansion focus on extending coverage to the uninsured, financial support for rural hospitals (particularly in light of upcoming cuts in Disproportionate Share Hospital funding7), and the economic benefits of new jobs in Missouri.
Because Missouri opted not to operate its own Marketplace, the federal government operates the Marketplace in the state.8 On March 4, 2015, the Supreme Court heard arguments in King v. Burwell challenging the legality of subsidies to people who purchased insurance through Federally-run Marketplaces. The Supreme Court will provide their ruling by the end of their term in June 2015. If they rule in favor of the plaintiffs, individuals who purchased coverage through the Marketplace with a subsidy would lose that subsidy, likely making such coverage unaffordable for them. Additionally, the employer requirement for coverage under the ACA, which goes into effect in 2015 and requires firms with more than 50 workers to pay a penalty if they do not offer affordable coverage and an employee purchases subsidized coverage through the Marketplace, would be nullified.9
Outreach and Enrollment in 2014
Like many other states, before open enrollment for 2014 coverage began, the Missouri General Assembly passed legislation creating requirements for outreach and enrollment workers, known as navigators. While these requirements were struck down by a Federal judge in January 2014, the legislature has continued to propose or pass legislation that navigators must pass exams, secure bonds, and pass background checks.10 Despite this climate and limited funding, advocates and other state organizations worked to enroll those eligible for coverage.11
On October 1, 2013, open enrollment for 2014 coverage began, but in the first few months, people experienced numerous technical difficulties with the Federal Marketplace website. By the end of open enrollment in 2014, 152,335 people had enrolled in Marketplace coverage in Missouri, accounting for 24% of the Missouri Marketplace eligible, a little below the national average of 28% of Marketplace eligible enrolling.12 Enrollment rates varied within the state, tending to be higher in urban and suburban areas than in rural areas.13
The federal government sends applications for enrollees ineligible for Marketplace enrollment to the state to determine Medicaid eligibility. However, in 2014, there were problems synchronizing the two websites. The Missouri Department of Social Services reported receiving 56,000 applications for MO HealthNet in PDF form that needed to be entered by hand. Most of these applications were deemed ineligible for MO HealthNet, but this influx of applications led in part to a backlog.14 In July of 2014, CMS announced that they would be monitoring the backlog of Medicaid applications in Missouri as well as five other states.15 Missouri has worked to resolve these issues, and as of February 2015, the state reported that there were 14,000 applications waiting to be reviewed, which Missouri Social Services deems to be close to an acceptable case-load.16 Regardless, monthly MO HealthNet enrollment has remained relatively low, increasing by 3.5 percent since before the ACA, as of February 2015.17 It is possible that some of this slow enrollment growth is explained by the recovering economy.18