Being Low-Income and Uninsured in Missouri: Coverage Challenges during Year One of ACA Implementation


In January 2014, the major coverage provisions of the 2010 Affordable Care Act (ACA) went into full effect in Missouri and across the country. These provisions include the creation of a new Health Insurance Marketplace where people can purchase coverage and middle income families (between about $27,300 and $79,200 for a family of three in 2014) can receive premium tax credits to offset the cost. In Missouri, the federal government is operating the Marketplace through the portal, as the state decided to not operate its own. Under the ACA, the Medicaid expansion was intended to be the means of providing affordable coverage to low-income adults (about $27,300 or less for a family of three in 2014), but the Supreme Court’s 2012 ruling in NFIB v. Sebelius effectively made Medicaid expansion optional for states. As of May 2015, Missouri had not expanded its Medicaid program, known as MO HealthNet. As a result of this decision, many low-income adults in Missouri remain without affordable health insurance options.

The majority (64%) of adults who remain without insurance coverage in Missouri are in the income range for Medicaid expansion. There is no deadline for the state to opt to expand its Medicaid program, and many in the state continue to argue for expansion. To inform this debate, this report uses the 2014 Kaiser Survey of Low-Income Americans and the ACA to profile who the low-income uninsured adults in Missouri are, what their health care access and financial security experiences have been, and why they remain uninsured. Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA, fielded prior to the start of open enrollment for 2014 Marketplace coverage, provided a baseline snapshot of health insurance coverage, health care use and barriers to care, and financial security among the insured and uninsured adults at the starting line of ACA implementation and discussed how those findings could inform early implementation.1 The 2013 survey included both a national sample and a Missouri sample, funded by the Missouri Foundation for Health. In the fall of 2014, we conducted a second wave of the Kaiser Survey of Low-Income Americans and the ACA nationally and in Missouri (again with support from the Missouri Foundation for Health) to understand how these factors changed under the first year of the law’s main coverage provisions. The survey, which included a state-representative sample of 1,864 nonelderly (age 19-64) Missouri adults, was conducted between September 2 and December 15, 2014, with the majority of interviews (68%) conducted prior to November 15, 2014 (the start of open enrollment for 2015 Marketplace coverage; Medicaid enrollment is open throughout the year).

To provide a meaningful comparison for the low-income uninsured in the state, we compare their experience to that of other low-income populations. Specifically, we compare the uninsured with incomes at or below 138% of poverty (“the low-income uninsured”) to enrollees in Missouri’s Medicaid program, also known as “MO HealthNet,” the program that would serve most uninsured adults should the state expand Medicaid. Most (79%) MO HealthNet enrollees have incomes below 138% of poverty. In stark contrast, however, only about one in ten (11%) of the privately insured in Missouri have family incomes at or below 138% of poverty. Thus, in comparisons to the privately insured, we restrict the analysis to the privately insured with incomes at or below 138% of poverty (“the low-income privately insured”). Additional tables provide parallel results for insured and uninsured individuals in higher income groups. A full description of the methods underlying the survey and analysis are available online.

Executive Summary Background: ACA Implementation in Missouri

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