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

Policy Implications

Though the Affordable Care Act was signed into law five years ago, the state is still debating whether to expand Medicaid to cover low-income uninsured adults. As a result, many low-income Missourians remain uninsured and without an affordable coverage option. These individuals face substantial barriers to accessing needed care and financial hardship as a result of remaining without coverage.

Without Medicaid expansion, most uninsured adults are likely to remain uninsured. The low-income uninsured in Missouri have been uninsured for a long time: seven in ten have been uninsured for more than one year.  Many low-income uninsured tried to obtain health insurance in 2014; however, cost ultimately is the major barrier preventing obtaining insurance. Without significant financial assistance, most uninsured adults are likely to remain without coverage. Further, few are likely to gain coverage through a job. The majority of the low-income uninsured are not eligible for health insurance through their employer, even though most are in a working family. Additionally, a lack of health insurance can affect a person’s ability to work: the survey showed that about a quarter of the low-income uninsured postponed care and as a result lost time at work, school, or other life activities. This finding suggests that for many in Missouri, being low-income and uninsured can lead to a cycle of being low-income and uninsured. Last, while some low-income uninsured in the state are eligible for tax credits for private coverage through the Marketplace, take-up in Missouri has lagged that of other states, and many who have sought or purchased Marketplace coverage indicate that they continue to face affordability challenges.¹

The safety net of clinics and health centers continues to play a pivotal role in serving the uninsured population in the state. With nearly four in ten of the low-income uninsured who have a usual source of care identifying health centers or clinics as that source of care, there is a demonstrated continued need for the health care safety net.  While federally qualified heath centers (FQHCs) in states that expanded Medicaid are encountering increased revenues as Medicaid pays for a larger share of their patients’ services,² health centers in Missouri are not seeing an infusion of revenues due to coverage gains. If the Supreme Court decides in King v. Burwell that subsidies are to be made available only to those that obtained insurance in a state-based marketplace, Missouri FQHCs will also lose revenue from patients who can no longer afford their private coverage purchased through the Marketplace.³ In addition to the strain placed on FQHCs, hospitals that received DSH funding will encounter cuts to their funding starting in 2018,⁴ without the expected balance of an increase in the number of Medicaid patients. This strain is may affect hospital financial viability, especially those in rural areas. In 2014, two of Missouri’s 74 rural hospitals shut down, further contributing to Missouri’s already known problem of primary care health professional shortages. 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.

Enrollment simplification and patient navigation may improve enrollment and use of services for adults in MO HealthNet. The survey indicates that some uninsured people are waiting to know if they are eligible for coverage or not. About one in six of the low-income uninsured who tried to obtain insurance reported that their application was still pending.  In July 2014, CMS began monitoring the MO HealthNet application backlog, as at one point in 2014, there were over 50,000 MO HealthNet applications that were waiting to be reviewed. Missouri reports that they have worked out many of the issues causing this, and have reduced the backlog substantially,⁵ but this finding is a reminder of the effect of a backlog, and the importance of coordination between the federally-facilitated Marketplace and MO HealthNet application systems.

Once people who are eligible for MO HealthNet are able to obtain insurance, they may encounter access to care issues. The survey findings indicate that nearly half of those enrolled in MO HealthNet said they postponed or went without needed care in 2014.  Although four out of five MO HealthNet enrollees did eventually get all needed care, this finding suggests a potential for improving patient navigation within the MO HealthNet program. MO HealthNet enrollees may experience delays in care for several reasons, including difficulty finding a provider, challenges in traveling to providers or getting time off work to see providers, or difficulty navigating plan networks. Future work that investigates what drives these challenges will be important to ensuring timely access to needed services and that Medicaid works for the people it covers.