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. These provisions include the creation of a new Health Insurance Marketplace where people can purchase coverage and middle income families can receive premium tax credits to offset the cost. In Missouri, the federal government is operating the Marketplace, as the state decided to not operate its own. The ACA also included an expansion of Medicaid to cover low-income adults, but the Supreme Court’s 2012 ruling effectively made Medicaid expansion optional for states. As of May 2015, Missouri had not expanded its Medicaid program, known as MO HealthNet, to cover more adults under the ACA. As a result of this decision, many low-income adults in Missouri remain without affordable health insurance options. Using findings from the 2014 Kaiser Survey of Low-Income Americans and the ACA, this report examines the uninsured population who would largely be eligible for Medicaid if Missouri were to expand. Specifically, it focuses on the low-income uninsured in Missouri, comparing who they are, their access to health care, and their financial situation to those enrolled in Missouri’s Medicaid program and to the low-income privately insured. It also examines why low-income uninsured adults in the state remain uninsured and their options for gaining coverage in 2015.

Key Findings

Who Are the Low-Income Uninsured in Missouri?

Because coverage options for the low-income uninsured in Missouri are largely the same as before the ACA, few people gained coverage in 2014, and the profile of the low-income population without coverage is largely the same as it was before the ACA. As in the past, being uninsured is a long-term problem: seven in ten of the low-income uninsured report having been uninsured for more than one year. The majority of the low-income uninsured are non-Hispanic White, about half are male, and the majority are under 35. About four in ten low-income uninsured have dependent children, as does about four in ten low-income privately insured, but the children of the low-income privately insured are more likely to be insured. Low-income uninsured adults are more likely to report having poorer health than the low-income privately insured, and they are also more likely to have unmet health needs.

How Do the Low-Income Uninsured Access Care?

As in the past, where we found that low-income adults without coverage in Missouri continue to lag behind their insured counterparts in access to care, this year’s survey findings continue to show access barriers among uninsured adults in the state. The low-income uninsured are less likely than MO HealthNet enrollees or the low-income privately insured to report having a usual source of care or to have a regular doctor at a usual source of care, indicating that they are less likely to be linked to care than others.  The low-income uninsured also use medical care at lower rates and ultimately go without needed care more frequently than those enrolled in MO HealthNet or the low-income privately insured. When uninsured adults do receive care, clinics and health centers are an important source of care for them: of those with a usual source of care, four in ten usually go to a doctor’s office or HMO1 for their care, and about four in ten go to a clinic or health center.

How Does Coverage Affect Financial Security?

Although all low-income people in the state experience varying degrees of financial insecurity, low-income uninsured adults’ financial insecurity is exacerbated by their lack of insurance. The low-income uninsured report higher rates of having problems paying medical bills than those enrolled in MO HealthNet or the low-income privately insured. Although many of those enrolled in MO HealthNet are generally financially insecure, only a third are not confident they can afford usual medical costs and only a third are not confident they can afford major medical costs. By contrast, over three quarters of the low-income uninsured are not confident they can afford usual medical costs, and close to nine out of ten are not confident that they can afford major medical costs. This worry has an effect on people’s well-being: a third of the low-income uninsured report that worry about medical costs affected their job performance, family relationships, or ability to sleep.

Why Are People Still Uninsured and What Are Their Coverage Options?

The majority of low-income uninsured adults say that the main reason they remain uninsured is because of cost. Fewer low-income uninsured in Missouri than a year ago say the main reason they are uninsured because of job-related reasons, such as not being employed or not being eligible for employer provided coverage. Nearly half of low-income uninsured adults tried to obtain MO HealthNet or Marketplace insurance in 2014, but most were told they were ineligible or found the coverage available to be unaffordable. The majority of the low-income uninsured are not eligible for employer sponsored coverage, either because they do not work, their employer doesn’t offer coverage, or they are not eligible for employer sponsored coverage, leaving them with few options for affordable coverage in 2015. Few low-income uninsured adults said they thought they would gain coverage in the upcoming year.

Policy Implications

The survey findings indicate that many low-income uninsured sought insurance coverage in 2014 but found few affordable options. The majority are not eligible for coverage through an employer, even though most are in a working family. Purchasing non-group coverage is the only remaining option for most, but those under the poverty level are ineligible for subsidies in the Marketplace. As a result, insurance remains too expensive for many. However, uninsured adults in the state still have health needs, many of which are not being adequately met, and will continue to face financial hardship in meeting those needs without a source of coverage.

Without the Medicaid expansion, the safety net remains an important source of care for the uninsured in the state. However, these providers face the possibility of revenue cuts in the future. Disproportionate Share Hospital (“DSH”) funding to hospitals will decline starting in 2018, without the expected balance of an increase in the number of Medicaid patients. Further, the Supreme Court decision in King v. Burwell may eliminate subsidies for people covered through the federal marketplace, leaving community clinics with less revenue if privately insured patients cannot afford insurance without subsidies. Ultimately this strain may limit the amount of care that the safety net can provide to the uninsured. If coverage options remain limited for low-income individuals in the state, it will be important to continue to monitor the ability of the uninsured to access services and the capacity and fiscal stability of the providers that serve them.

Lastly, the survey indicates some areas of improvement for MO HealthNet as it exists now. Some low-income uninsured reported that their insurance application was still pending as of Fall 2014, serving as a reminder of the importance of a streamlined application system. In addition, the survey shows MO HealthNet enrollees are linked to and use the health care system, but about half have encountered delays in needed services. While most ultimately do receive the care that they need, ensuring timely access to needed services is an important policy goal in making sure Medicaid works for the people it covers.


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