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

Executive Summary
  1. Rachel Garfield, Rachel Licata, and Katherine Young, The Uninsured at the Starting line:  Findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA (Washington, DC:  Kaiser Family Foundation, 2014), https://www.kff.org/uninsured/report/the-uninsured-at-the-starting-line-findings-from-the-2013-kaiser-survey-of-low-income-americans-and-the-aca/.

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  2. Kaiser Commission on Medicaid and the Uninsured, The Uninsured:  A Primer- Key Facts about Health Insurance on the Eve of Coverage Expansions (Washington, DC:  Kaiser Family Foundation), October 23, 2013, https://www.kff.org/uninsured/report/the-uninsured-a-primer-key-facts-about-health-insurance-on-the-eve-of-coverage-expansions/.

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  3. All states previously expanded eligibility for children to higher levels than adults through Medicaid and the Children’s Health Insurance Program (CHIP), and in Missouri, children with family incomes up to 305% of poverty (about $71,800 for a family of four) are eligible for Medicaid or CHIP. As was the case before the ACA, undocumented immigrants remain ineligible to enroll in Medicaid and recent lawfully residing immigrants are subject to certain Medicaid eligibility restrictions.

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  4. Kaiser Family Foundation, “How Will the Uninsured in Missouri Fare Under the Affordable Care Act?” (Washington, DC: Kaiser Family Foundation), January 6, 2014, https://www.kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-missouri/

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  5. Leighton Ku, PhD, MPH, et al. “Coordinating and Integrating Care for Safety Net Patients:  Lessons from Six Communities,” George Washington University, Washington, DC (May 21, 2012). U.S. Census Bureau, 2010 Census.

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Introduction
  1. Garfield, The Uninsured at the Starting Line.

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Background: The Challenge of Expanding Health Coverage in Missouri
  1. Care without Coverage: Too Little, Too Late, Committee on the Consequences of Uninsurance, Board on Health Care Services, Institute of Medicine, National Academy Press, 2002

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  2. J. Hadley, J. Holahan, T. Coughlin, and D. Miller, 2008 “Covering The Uninsured In 2008: Current Costs, Sources Of Payment, And Incremental Costs” Health Affairs 27 (5) w399 (published online 25 August 2008).

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  3. G. Anderson, 2007, “From ‘Soak The Rich’ To ‘Soak The Poor’: Recent Trends In Hospital Pricing.” Health Affairs 26(4): 780-789.

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  4. D. Himmelstein et al., 2009. “Medical bankruptcy in the United States, 2007: results of a national study.” Am J Med. 122(8): 741-6. Available at: http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf.

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  5. Kaiser Family Foundation, The Uninsured:  A Primer, 2013.

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  6. Kaiser Family Foundation analysis of HRSA Data on Health Professional Shortage Areas, by state, as of January 1, 2014.

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  7. Melissa Van Dyne, Marie Ballew, Ben Harvey, et al., Rural Health Biennial Report 2012-2013 (Jefferson City, MO:  Office of Primary Care and Rural Health, 2014), http://health.mo.gov/living/families/ruralhealth/pdf/biennial2013.pdf.

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  8. Ibid.

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  9. Ibid.

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  10. American Community Survey, 2009-2012. American Fact Finder, March 6, 2014.

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  11. Single race only. U.S. Census Bureau, 2010 Census. American Fact Finder, March 6, 2014.

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  12. Kaiser Commission on Medicaid and the Uninsured, Status of State Medicaid Expansion Decisions, State Health Facts, Retrieved March 6, 2014 from http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/

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  13. Kaiser Family Foundation, “How Will the Uninsured in Missouri Fare Under the Affordable Care Act?” (Washington, DC: Kaiser Family Foundation), January 6, 2014, https://www.kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-missouri/

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  14. Ibid.

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  15. Ibid.

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  16. Leighton Ku, Coordinating and Integrating Care for Safety Net Patients.

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  17. Ibid.

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  18. Ibid.

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  19. “Gateway to Better Health Extended to 2015,” St. Louis Regional Health Commission, St. Louis (September 28, 2013). Available at http://www.stlrhc.org/wp-content/uploads/2013/09/Gateway-to-Better-Health-Program-Extended-to-20152.pdf

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  20. Gateway to Better Health, 2013.

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  21. Kaiser Family Foundation, Uninsured in Missouri.

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  22. Ibid.

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  23. Kaiser Family Foundation, “State Exchange Profiles:  Missouri,” Access March 8, 2014, https://www.kff.org/health-reform/state-profile/state-exchange-profiles-missouri/

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  24. Ibid.

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  25. Centers for Medicare and Medicaid Services, “Missouri Medicaid Moving Forward in 2014,” Accessed March 6, 2014, http://medicaid.gov/Medicaid-CHIP-Program-Information/By-State/missouri.html

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  26. Centers for Medicare and Medicaid Services, Missouri Medicaid.

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  27. “Governor Nixon Delivers 2014 State of State Address,” Office of Missouri Governor Jay Nixon, January 21, 2014, Available at http://governor.mo.gov/news/archive/gov-nixon-delivers-2014-state-state-address-0

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  28. Missouri HB 1901. Full text available http://www.house.mo.gov/billsummary.aspx?bill=HB1901&year=2014&code=R  Virginia Young, “Missouri House Republican Files Medicaid Expansion Bill,” Kaiser Health News, February 20, 2014. Available at http://www.kaiserhealthnews.org/stories/2014/february/20/missouri-medicaid-expansion.aspx

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  29. Missouri Economic Research and Information Center, “The Economic Impact of Medicaid Expansion,” (Missouri:  Missouri Department of Economic Development), February 21, 2014, http://www.missourieconomy.org/medicaidreport.pdf

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  30. Timothy McBride, Sidney Watson, Amy Blouin, “The Missouri Medicaid Expansion:  Good for All Missourians,” Missouri Budget Project, January 2013, Available at http://www.mobudget.org/files/medicaid_expansion_rural_1-2013.pdf

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  31. Paul Demko, “Federal judge strikes down Missouri’s regulations on exchange navigators, other outreach workers,” Modern Healthcare, January 24, 2014. Available at:  http://www.modernhealthcare.com/article/20140124/NEWS/301249974#   “Navigators Licensing Requirements and Application,” Missouri Department of Insurance, Available at http://insurance.mo.gov/otherlicensees/navigators.php

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  32. Demko, 2014.

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  33. Missouri SB 508. Full text available http://www.senate.mo.gov/14info/BTS_Web/Bill.aspx?SessionType=R&BillID=27723555 Jordan Shapiro, “Missouri Senate bills would impose requirements on health insurance exchange navigators,” The Republic, February 17, 2014. Available at http://www.therepublic.com/view/story/c12e020a510b4cafa680a7125d027914/MO-XGR--Health-Care-Exchange-Navigators

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  34. Tara Kulash, “Missouri Pulls Out Stops, But Lags Better-Funding Illinois Effort,” Health Care in the States, Kaiser Health News, March 11, 2014. http://capsules.kaiserhealthnews.org/index.php/2014/03/missouri-pulls-out-stops-but-lags-better-funded-illinois-effort/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog)

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  35. CMS, Missouri Moving Forward in 2014.

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  36. Kaiser Family Foundation, “State Marketplace Statistics,” State Health Facts, Accessed March 6, 2014 from https://www.kff.org/health-reform/state-indicator/state-marketplace-statistics-2/

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  37. “Medicaid & CHIP:  January 2014 Monthly Applications and Eligibility Determinations Report,” Centers for Medicare and Medicaid Services, February 28, 2014. Accessed March 12, 2014 from http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/January-2014-Enrollment-Report.pdf

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  38. Virginia Young, “Medicaid applications from HealthCare.gov called flawed; Missouri enrollment dips,” St. Louis Post-Dispatch, February 4, 2014. Available at http://www.stltoday.com/news/special-reports/mohealth/medicaid-applications-from-healthcare-gov-called-flawed-mo-enrollment-dips/article_a4c715f2-02ad-5a1b-9204-634d7e0531ee.html

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  39. Young, Medicaid applications, 2014.

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I. Patterns of Coverage and the Need for Assistance
  1. See “Protections in individual insurance markets” at https://www.kff.org/state-category/health-insurance-managed-care/.

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  2. On February 10, 2014, the Obama Administration delayed penalties associated with this Employer Responsibility Provision until 2015. U.S. Department of the Treasury, Treasury and IRS Issue Final Regulations Implementing Employer Shared Responsibility Under the Affordable Care Act for 2015 (February 10, 2014), http://www.treasury.gov/press-center/press-releases/Pages/jl2290.aspx.

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  3. Excludes undocumented immigrants.

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  4. Collins S, et al. 2012. “Gaps in Health Insurance: Why So Many Americans Experience Breaks in Coverage and How the Affordable Care Act Will Help.” The Commonwealth Fund. http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Apr/1594_collins_gaps_in_hlt_ins_tracking_brief_v2.pdf;  Cassedy A, Fairbrother G, and Newacheck PW. 2008. “The Impact of Insurance Instability on Children’s Access, Utilization, and Satisfaction with Health Care. Ambulatory Pediatrics. 8(5):321-8.

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  5. Martha Heberlein, et al., Getting into Gear for 2014:  Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 (Kaiser Family Foundation), January 2013.

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II. What to Look for in Enrolling in New Coverage
  1. Ibid.

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  2. For more information, see: Martha Heberlein, Tricia Brooks, Samantha Artiga, and Jessica Stephens, Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies into Drive (Kaiser Family Foundation), November 2013, http://www.kff.org/medicaid/report/getting-into-gear-for-2014-shifting-new-medicaid-eligibility-and-enrollment-policies-into-drive/.

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  3. Martha Heberlein, et al., Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies into Drive (Kaiser Family Foundation), November 2013.

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  4. Includes people who had a choice of plans and reported that they made the choice themselves.

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  5. Zhou, C. and Zhang, Y. (2012). The vast majority of Medicare Part D beneficiaries still don’t choose the cheapest plans that meet their medication needs.  Health Affairs, 31: 2259-2264; McLaughlin, C.G., Chernew, M., & Taylor, E.F. (2002).  Medigap premiums and Medicare HMO enrollment.  Health Services Research 37: 1445-1468.

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  6. Kaiser Commission on Medicaid and the Uninsured. Oral Health and Low-Income Nonelderly Adults:  A Review of Coverage and Access (Washington, DC:  Kaiser Family Foundation), June 2012.  Available at: http://www.kff.org/medicaid/issue-brief/access-to-affordable-dental-care-gaps-for/.

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III. Gaining Coverage, Getting Care
  1. Institute of Medicine, Committee on the Consequences of Uninsurance, Board on Health Care Services, Care without Coverage: Too Little, Too Late (Washington, DC: National Academy Press: Institute of Medicine), May 2002, http://www.iom.edu/~/media/Files/Report%20Files/2003/Care-Without-Coverage-Too-Little-Too-Late/Uninsured2FINAL.pdf.

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  2. Institute of Medicine, Committee on the Consequences of Uninsurance, Board on Health Care Services Coverage Matters: Insurance and Health Care (Washington, DC: National Academy Press: Institute of Medicine), 2001.

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  3. Julia Paradise and Rachel Garfield, What is Medicaid’s Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight on Evidence (Washington, DC:  Kaiser Commission on Medicaid and the Uninsured), August 2, 2013, https://www.kff.org/medicaid/issue-brief/what-is-medicaids-impact-on-access-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence.

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  4. Kaiser Family Foundation, “Health Insurance Market Reforms:  Pre-Existing Condition Exclusions,” (Washington, DC:  Kaiser Family Foundation), October 8, 2012. https://www.kff.org/health-reform/fact-sheet/health-insurance-market-reforms-pre-existing-condition/

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  5. Stephen Zuckerman and Dana Goin, The Urban Institute, How Much Will Medicaid Physician Fees for Primary Care Rise in 2013?  Evidence from a 2012 Survey of Medicaid Physician Fees, (Washington, DC:  Kaiser Commission on Medicaid and the Uninsured, December 2012), https://www.kff.org/medicaid/issue-brief/how-much-will-medicaid-physician-fees-for/.

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  6. Sandra L. Decker, “Two-thirds of Primary Care Physicians Accepted New Medicaid Patients in 2011-12: A Baseline to Measure Future Acceptance Rates,” Health Affairs 32, no. 7 (Jul. 2013): 1183-7, http://content.healthaffairs.org/content/32/7/1183.abstract.

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  7. Garfield, The Uninsured at the Starting Line.

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  8. Kaiser Commission on Medicaid and the Uninsured, Community Health Centers in an Era of Health Reform: An Overview and Key Challenges to Health Center Growth (Washington, DC:  Kaiser Family Foundation), March 1, 2013, https://www.kff.org/health-reform/issue-brief/community-health-centers-in-an-era-of-health-reform-overview/.

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IV. Health Coverage and Financial Security
  1. “MO HealthNet for the Aged, Blind and Disabled – Who is Eligible,” Missouri Department of Social Services, June 4, 2013. Retrieved March 11, 2014 from http://www.dss.mo.gov/fsd/massist.htm For additional information on medically needy coverage please see:  https://www.kff.org/medicaid/issue-brief/the-medicaid-medically-needy-program-spending-and/

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Conclusion & Policy Implications
  1. Cynthia Cox, Gary Claxton, Larry Levitt, Hana Khosla. An Early Look at Premiums and Insurer Participation in

    Health Insurance Marketplaces, 2014. Kaiser Family Foundation, Updated Table, as of October 22, 2013; available at: https://www.kff.org/health-reform/issue-brief/an-early-look-at-premiums-and-insurer-participation-in-health-insurance-marketplaces-2014/.

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  2. State Health Facts, State Marketplace Statistics.

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  3. Ibid.

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Methods