The Uninsured at the Starting Line in Missouri: Missouri findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA

The 2010 Affordable Care Act (ACA) has the potential to reach many of the 47 million Americans who lack insurance coverage, including over 800,000 in Missouri, as well as millions of insured people who face financial strain or coverage limits related to health insurance. In January 2014, the major coverage provisions of the ACA went into full effect. These provisions include the creation of new Health Insurance Marketplaces where low and moderate income families can receive premium tax credits to purchase coverage and, in states that opted to expand their Medicaid programs, the expansion of Medicaid eligibility to adults with incomes at or below 138% of the federal poverty level (FPL). The marketplace in Missouri is federally facilitated, as the state opted not to run its own. In addition, as of March 2014, Missouri had not expanded its Medicaid program, leaving many uninsured adults below poverty in Missouri who would have been newly-eligible for Medicaid without a coverage option.

Though ACA implementation is underway in Missouri and across the country and people are already enrolling in coverage, policymakers continue to need information on the uninsured population. Reports of difficulties in enrolling in coverage, continued confusion and lack of information about the law point to challenges in the early stages of implementation, and information about the population targeted for coverage expansion can inform efforts to address these difficulties. In addition, because Missouri could still opt to expand its Medicaid program, it is important to have detailed data on the population that could benefit from such a coverage expansion. Specifically, information on poor and moderate–income adults’ experiences with health coverage, current patterns of care, and family situations can provide insight into some of the challenges that are arising in the first months of coverage and highlight the potential impact of gaining coverage on poor and moderate- income adults.

This report, based on findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA, provides a snapshot of health insurance coverage, health care use and barriers to care, and financial security among insured and uninsured Missouri adults across the income spectrum at the starting line of ACA implementation. The survey, conducted between July and September 2013, is a nationally representative survey that also includes a state-representative sample of over 1,800 nonelderly (age 19-64) adults in Missouri. It was designed to focus on the low- and moderate-income populations in the state and includes over-samples of people in the income range for financial assistance under the ACA (< 138% FPL for Medicaid and 139-400% FPL for Marketplaces), as well as a comparison group with incomes over 400% FPL. Since many uninsured adults with incomes below 100% FPL are left in a coverage gap in Missouri, our analysis focused on poor adults (<100% FPL) and moderate-income adults (100%-400% FPL) who will be eligible for premium subsidies. The survey includes adults with employer coverage, nongroup, Medicaid, and other sources of coverage, as well as those with no health insurance. The Missouri component of the survey and report on its findings complements a report on similar findings for the nation.¹

This survey and report provides new data to help policymakers further understand early challenges in implementing health reform and highlight the health insurance and health care needs of those who may remain uninsured. This survey also provides a baseline for future assessment of the impact of the ACA in Missouri on health coverage, access, and financial security of poor and moderate-income individuals. Detailed information on the survey design, sample, and analysis can be found in the Methods section at the end of the full report.

Background: The Challenge of Expanding Health Coverage in Missouri

Prior to implementation of the ACA, 834,000 Missourians—16% of the state’s nonelderly population—were without health insurance coverage. Because publicly-financed coverage has already been expanded to most low-income children and Medicare covers nearly all of the elderly, the vast majority of uninsured people in Missouri and across the country are nonelderly adults.² The main barrier that people have faced in obtaining health insurance coverage is cost: health coverage is expensive, and few people can afford to buy it on their own. While most Americans traditionally obtain health insurance coverage as a fringe benefit through an employer, not all workers are offered employer coverage. Medicaid covers many low-income children, but eligibility for parents was limited before the ACA and nonexistent for childless adults, leaving many adults without affordable coverage. As of January 2014, Medicaid eligibility for adults in Missouri is limited to parents with incomes below 23% of poverty, or about $5,500 a year for a family of four.³ Adults without dependent children are ineligible regardless of their income.⁴

Barriers to coverage are reflected in the characteristics of the uninsured population in Missouri. Uninsured Missouri adults are more likely to be poor than Missourians with private health insurance (including employer coverage and nongroup coverage), while adults with Medicaid coverage are particularly poor (reflecting eligibility limits). Though the majority of uninsured adults are in a family with either a full- or part-time worker, uninsured Missouri adults are less likely than privately insured adults to be in families with either a full- or part-time worker. The unique demographics of the state population also play a role in shaping the profile of uninsured Missourians. Missouri’s population resides in both rural and urban settings. The rural population is very low-income, leaving a large percentage of that population uninsured. The population in Missouri’s two major cities is very diverse with a majority of the population in St. Louis identifying as a race other than White.⁵ These geography and demographic differences have implications for outreach efforts as well as access to care as many uninsured adults in Missouri will likely remain uninsured in 2014 without a Medicaid expansion.

I. Patterns of Coverage and the Need for Assistance

Examining patterns of coverage and the reasons the uninsured lack coverage can inform both outreach avenues and potential barriers to outreach and enrollment. Key survey findings on access to coverage include:

For many currently uninsured adults in Missouri, lack of coverage is a long-term issue. While some people experience short spells of uninsurance due to job changes, income fluctuations, or renewal issues, for many uninsured Missouri adults, lack of coverage is a chronic issue. The survey shows that 43% of uninsured adults report being uninsured for 5 years or more, including 14% of the uninsured who report that they have never had coverage in their lifetime.

Many uninsured adults in Missouri report trying to obtain insurance coverage in the past, but most did not have access to affordable coverage. Prior to the ACA, Missouri’s uninsured reported difficulty gaining insurance coverage due to the high cost of coverage and limits on Medicaid eligibility for adults. More than eight in ten (83%) uninsured adults report no access to employer insurance, and the majority of people who had access to coverage through an employer report that the coverage offered to them is not affordable. One-third of uninsured Missouri adults (34%) reported trying to sign up for Medicaid in the past five years, and the majority of them were unsuccessful because they were told they were ineligible. And one in four uninsured Missouri adults (25%) reported trying to obtain nongroup coverage in the past five years, with most not purchasing a plan because the policy they were offered was too expensive.

Health insurance coverage is not always stable. For most insured adults in Missouri, coverage is continuous throughout the year and over time, but a sizable number have a gap or change in coverage. When accounting for both insured Missourians with a gap in their coverage and uninsured Missourians who recently lost coverage, the survey indicates that 11% of adults in Missouri, or almost 400,000 people, lose or gain coverage over the course of a year. In addition to those who lose or gain coverage over the course of a year, 320,000 continuously insured adults report having a change in their health insurance plan. The most common reasons for a change in coverage appear to be related to employment. Last, a small number of insured Missouri adults report challenges in either renewing or keeping their coverage, another indication of instability in coverage throughout the year.

Informing Missouri’s ACA Implementation: Many of the barriers to coverage that Missouri’s uninsured reported facing in the past are addressed by the ACA’s provisions to expand Medicaid and provide premium tax credits for Marketplace coverage. However, since Missouri has not expanded Medicaid coverage at this time, many uninsured adults will be left in a coverage gap and will remain uninsured. In addition to limited coverage options, some uninsured adults may continue to face financial and other barriers to coverage. Missourians targeted by the ACA have varying levels of experience with the insurance system. A large share of uninsured adults in Missouri has been outside the insurance system for quite some time, and the long-term uninsured may require targeted outreach and education efforts to link them to the health care system and help them navigate their new health insurance. In addition, people who have attempted to obtain coverage in the past may be unaware that rules and costs have changed under the ACA; outreach and education will be needed to inform people that financial assistance is available to offset the cost of private coverage.

While there has been much focus on enrolling currently uninsured people into coverage, survey findings demonstrate that people will continue to move around within the insurance system throughout the year as their income or job situations change. Thus, implementation is not a “one shot” effort that will be done once open enrollment ends in March 2014, but rather will require a continuous effort to enroll and keep people in coverage. Also, if Missouri decides to later expand Medicaid, a second round of outreach and enrollment strategies will be needed to inform uninsured adults of this policy change.

II. What to Look for in Enrolling in New Coverage

While many currently uninsured adults in Missouri have limited experience in signing up for and using health coverage, the past successes and challenges of insured poor and moderate-income adults can inform the experiences of those seeking coverage under the ACA. Key survey findings related to plan enrollment and plan choice are:

While many adults in Missouri report facing no difficulty in applying for Medicaid coverage prior to the ACA, some encountered difficulties in the process of applying for public coverage in the past. Missouri adults who currently have Medicaid or who have attempted to enroll in the past five years reported little difficulty in taking steps to enroll in Medicaid, with almost half (49%) saying the entire process was very or somewhat easy. However, the rest found at least one aspect of the process – finding out how to apply, filling out the application, assembling the required paperwork, or submitting the application – to be somewhat or very difficult. The most commonly-reported difficulty assembling the required paperwork, which 37% of Missourians who applied or enrolled said was somewhat or very difficult.

When adults with Medicaid or private insurance have a choice of plan, they do not always prioritize costs over other plan features in making that choice, and many find some aspect of the plan choice process to be a challenge.  Adults chose health plans for various reasons, with 38% of those who had and made a choice of plan reporting that they chose their plan because it covered a wide range of benefits or a specific benefit that they need, 27% because their costs would be low, and 19% because the plan had a broad selection of providers or included their doctor. In choosing a plan, even if they have limited options, Missourians may face challenges in comparing costs, services, and provider networks, as these factors have typically varied greatly across plans in the past. In general, insured adults in Missouri report that they did not have difficulty in comparing their plan choices, but about a third found some aspect of plan choice—comparing services, comparing costs, and comparing providers— to be difficult.

Overall, adults in Missouri with employer coverage, nongroup, or Medicaid report satisfaction with their current coverage but also report gaps in covered services and problems when using their coverage. Most (84%) insured adults in Missouri rate their pre-ACA coverage as excellent or good, but they also report gaps in services that are covered by their current insurance. One in six (17%) insured adults in Missouri report needing a service that is not covered by their current plan, typically ancillary services, such as dental, vision care, and chiropractor services. Many insured adults in Missouri reported experiencing a problem with their current insurance plan covering a specific benefit, either because they were denied coverage for a service they thought was covered (23%) or their out-of-pocket costs for a service were higher than they expected (38%).

Informing ACA Implementation. The ACA includes provisions to simplify the Medicaid application and enrollment process for coverage. The ACA also requires plans in the Marketplace to provide detailed, standardized plan information for people to compare coverage options. Uninsured Missouri adults applying for coverage after these new processes are implemented should encounter fewer challenges in navigating enrollment and plan choice than applicants have in the past. However, in evaluating the success of plan enrollment, it is important to bear in mind that, even prior to the ACA, insured adults faced some challenges in comparing and selecting insurance coverage. While provisions in the ACA could address these challenges, some are inherent to the complexity of insurance coverage. It is also important to remember that people place utility on a range of factors related to insurance, including scope of services and provider networks. Assessments of whether people are choosing the optimal plan for themselves and their family will need to consider the multiple priorities that people balance in plan selection. Last, while the ACA aims to ensure coverage of at least a basic set of essential health benefits (EHB), many of the ancillary services that people report needing coverage for—such as dental services—are not included in the EHB. Newly-insured Missourians may be surprised to learn that some ancillary services are not included in their plan, and education efforts will be needed to help Missourians understand their coverage.

III. Gaining Coverage, Getting Care

As uninsured adults in Missouri gain coverage, there are likely to be changes in how often they seek care, what type of care they seek, and where they seek care. By comparing their current interactions with the health care system to their insured counterparts, the survey can provide insight into likely changes. It can also highlight potential ongoing unmet need among those who remain uninsured. Key findings in this area include:

A large segment of the uninsured in Missouri has little or no connection to the health care system. Many uninsured adults report few connections to the health care system. Only 55% of uninsured adults report that they have a usual source of care, or a place to go when they are sick or need advice about their health, and only 36% of uninsured adults say they have a regular doctor, about half of the rate of insured adults in Missouri. This lack of a connection to the health care system leads many uninsured adults to go without care. Six in ten uninsured adults in Missouri (60%) reported at least one health care visits in the past year, compared to 93% of Medicaid beneficiaries and 87% of adults with employer coverage.

Many uninsured Missourians have health needs, many of which are unmet or only met with difficulty. Uninsured adults are less likely than their insured counterparts to report receiving care for an ongoing health condition. When uninsured individuals do receive care, they sometimes receive free or reduced-cost care, though the majority who use services do not. More than half (56%) of the uninsured and more than half (54%) of Medicaid beneficiaries in Missouri report needing but postponing care, compared to 27% of adults with employer coverage. The most common reason for postponing care among the uninsured is cost, as the uninsured have no coverage to help them with the cost of care.

Many uninsured Missourians report limited options for receiving health care when they need it. Uninsured adults in Missouri are less likely than their insured counterparts to receive care in a private physician’s office when they do get care. Uninsured adults are about half as likely to report choosing their usual source of care because a preferred physician (26%) as compared to 49% of adults with Medicaid and 56% of adults with employer coverage.

Informing ACA Implementation: The survey findings reinforce conclusions based on prior research: having health insurance affects the way that people interact with the health care system, and people without insurance have poorer access to services than those with coverage. Thus, gaining coverage could connect many currently uninsured Missouri adults to the health care system. Given the health profile of Missouri’s currently uninsured population, there is likely to be some pent-up demand for health care services among the newly-covered. However, outreach may be needed to link the newly-insured to a regular provider and help them establish a pattern of regular preventive care. In particular, some individuals who have relied on emergency rooms or urgent care centers as their usual source of care may require help in establishing new patterns of care and navigating the primary care system. While Missouri’s uninsured may have more options for where to receive their care once they obtain coverage under the ACA, many uninsured adults will remain uninsured so safety net providers such as clinics and hospitals that already see a large share of uninsured adults may continue to play an important role in serving this population. Last, while coverage gains may reduce cost barriers to care, it will be important to monitor whether other barriers to care among the poor and moderate-income population—such as transportation or wait times for appointments—continue to pose a challenge for access.

IV. Health Coverage and Financial Security

In addition to facilitating access to health care, health insurance serves primarily to protect people from high, unexpected medical costs. However, for poor families in Missouri, health costs can still be a burden, even if they have insurance. Understanding these issues can help policymakers monitor ongoing financial barriers to health services.

Health care costs pose a challenge for poor and moderate-income families in Missouri, even if they have insurance coverage. Even among those with insurance, health care costs can be a burden, particularly for poor and moderate-income adults. Over three in ten (36%) poor and moderate-income adults in Missouri who are covered by employer coverage report that their share of the premium is somewhat hard or very hard for them to afford, and 62% of moderate-income adults in Missouri with nongroup coverage report difficulty paying their premiums. Health care costs translate to medical debt for many poor adults, and these medical bills can cause serious financial strain. Notable shares of poor insured adults also report that they lack confidence in their ability to afford health care, given their current finances and health insurance situation.

Poor families face fragile financial circumstances. Poor and moderate-income adults in Missouri across coverage groups report not being financially secure. However, adults who are poor and uninsured or covered by Medicaid are particularly vulnerable to financial insecurity even outside of health care. General financial insecurity translates to concrete financial difficulties in making ends meet. Uninsured adults and those enrolled in Medicaid are more likely than privately-insured adults to have difficulty paying for other necessities, such as food, housing, or utilities, with 49% of the uninsured and 61% of those on Medicaid reporting such difficulty compared to 20% of those with employer coverage and 25% of those with nongroup coverage. While poor adults across the coverage spectrum report high rates of difficulty paying for necessities, those with employer coverage report the lowest rates in this income group. These individuals may have stronger or more stable ties to employment than their counterparts with other or no insurance coverage. Higher rates of financial insecurity among Medicaid enrollees may reflect Medicaid eligibility rules, which targeted very vulnerable adults.

Informing ACA Implementation: Both insured and uninsured poor adults in Missouri struggle with medical bills and debt, and assistance with premium costs and, for some, cost-sharing, and limits on out-of-pocket costs under the ACA have the potential to ameliorate the financial issues associated with the cost of health care. Many uninsured poor adults will continue to face medical bills and debt as they are likely to remain uninsured without a Medicaid expansion. However, given survey findings that many poor insured Missourians continue to face financial challenges related to health care, it will be important to track whether there are ongoing financial barriers as people enroll in coverage and seek care. While insurance coverage can provide financial protection in the event of illness or injury, it is not curative of all of the financial burdens faced by poor families. Given their overall situation, health insurance alone may not lift poor Missourians out of poverty, and many poor Missouri adults may continue to face financial challenges even after gaining coverage.