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

Conclusion & Policy Implications

The survey findings related to: i) patterns of insurance coverage, ii) the process of enrolling in and choosing health coverage, iii) interactions with the health care system, iv) financial security, and v) readiness for ACA coverage expansions have implications for early implementation of the ACA in Missouri and for ongoing state debate over whether to expand Medicaid coverage. Uninsured adults in Missouri are generally in low-income, working families and have lacked insurance coverage for quite some time. Many have substantial health care needs but have only loose ties to the health system. Below, we summarize how this pre-ACA baseline data can inform outreach and enrollment, plan selection and scope of coverage, and providers and health systems and discuss the issues the uninsured will face without an expansion.

Reaching Eligible Uninsured Adults

Outreach and enrollment will be an ongoing process.While there is much focus on the initial push to enroll people in coverage under the ACA, enrollment is not a “one shot” effort that will be completed in the first few months of implementation. The survey findings reveal that thousands of Missourians lose and gain coverage throughout the year because of job changes, income fluctuations, or problems at renewal. Thus, implementing the ACA will require ongoing efforts to enroll and keep people in coverage, and efforts to promote coverage stability are important. Many uninsured adults will fall into a coverage gap without a Medicaid expansion, but if the state later decides to implement an expansion, another round of outreach and enrollment will be necessary to reach those left out by the initial open enrollment period.

Some eligible uninsured adults in Missouri have little or no connection to pre-ACA health or social services systems and may be hard to reach. Many people targeted for Marketplace coverage are not currently connected to the health care system, have been outside the health insurance system for quite some time, or are not linked to social services programs. The survey shows over four in ten uninsured adults have lacked coverage for five years or longer, most do not have a regular source of care, and many have no health care visits over the course of a year. While state efforts to limit the availability of outreach workers may have initially reduced enrollment efforts, continued efforts by advocates and established navigators will likely increase enrollment through the end of the first open enrollment period. Additional campaigns and coordination between HealthCare.gov and the state Medicaid agency will be necessary to bring more people into coverage.

Many eligible uninsured adults in Missouri have experience with pre-ACA health care, health insurance, or social services systems, but there is great need for continued education about new coverage options. Some people targeted for Marketplace coverage have experience with the health care system and health insurance but may be unaware that availability of coverage and costs have changed under the ACA. Despite news coverage of the ACA, notable shares reported in the survey that they were unaware of new coverage options at the start of open enrollment. Further, many reported pre-ACA experiences of trying to get coverage and encountering barriers. It will be important for outreach messages to emphasize how coverage options have changed in order to reach out to people who have tried to apply for coverage in the past. Education efforts will also be necessary to inform poor uninsured adults ineligible for coverage of their options.

Not all uninsured adults in Missouri have access to coverage expansions under the ACA, and many may remain uninsured and continue to experience issues accessing and paying for care. Because Missouri did not expand Medicaid in January 2014, about half of uninsured adults are left in a coverage gap of earning too much to qualify for Medicaid but not enough to qualify for premium tax credits in the Marketplace. The survey shows that poor uninsured adults have few options for coverage because they do not have access to employer coverage and nongroup coverage is unaffordable. Poor uninsured adults also reported high levels of financial insecurity and financial barriers to care as compared to their insured counterparts. As policymakers continue to debate an expansion of Medicaid, it is important to recognize the impact of coverage and the lack of options available to poor uninsured adults.

Connecting People to Suitable Coverage

In addition to technical issues with HealthCare.gov, it will be important to monitor whether other challenges in enrolling in health coverage that existed prior to the ACA are addressed by ACA simplification provisions. The federal government has made strides in addressing many of the website glitches that plagued early enrollment efforts under the ACA, and they continue to focus attention on addressing these technical issues. However, there are other challenges to enrolling in coverage and picking a plan that policymakers may still need to address. Survey results indicate that, before the ACA, some insured Missourians reported challenges assembling the required paperwork for Medicaid. Adults also reported challenges with the next stage of enrollment: comparing plan information to choose a plan. Despite the decision not to expand Medicaid in Missouri, the state must comply with the new enrollment simplification rules. The ACA also provides for enrollment assistance for people applying to both Marketplace coverage and Medicaid, but the state has a limited range of entities to provide one-on-one assistance with applications. While it is still early to evaluate the success or challenges of these efforts, it will be important to track implementation of these simplifications to ensure that challenges that some people faced in the past do not carry over to ACA enrollment.

Early assessments of plan choice under the ACA may account for the fact that cost is only one factor in Missourians’ preferences for health coverage. Much focus in early coverage of ACA enrollment has been on the premiums and deductibles that people will face under their new coverage. These features provide concrete measures that people can examine, and certainly costs are a key concern for new enrollees. However, the survey shows that Missourians also value other aspects of their coverage, such as benefits and networks, sometimes even more than low out-of-pocket costs. Future evaluations of coverage, therefore, may consider how well new plans are meeting the full range of priorities and preferences for health coverage, and future changes to plan offerings under the law may consider the broad range of people’s priorities for their coverage.

Even once Missourians have insurance, they may face issues with their plans covering the range and scope of services they need. Survey findings reveal that the vast majority of enrollees in various types of coverage reported being satisfied with their plan, but notable shares reported a problem with their scope of coverage. Many adults on Medicaid reported needing coverage for dental services that are not included in their plan, and Missourians with private coverage also reported gaps in ancillary services. In addition, while people gaining coverage in the Marketplace will receive coverage for essential health benefits, it will be important to assess whether the scope of coverage Missourians have under the law meets their needs and work to educate people about both what is and what is not included in their coverage.

While the ACA could ameliorate the financial burden of health care for many, affordability of health services may remain a challenge. In addition to the goal of facilitating access to health care services, a goal of coverage expansions is to provide financial protection from medical expenses. As survey findings show, even among Missourians who have insurance, health care costs can be a challenge. Though less likely than their uninsured counterparts to have difficulties with medical costs, poor insured adults in Missouri reported challenges in paying premiums, copayments, out-of-pocket costs for uncovered services, and other health care expenses. In addition, all poor families, regardless of insurance coverage, face financial hardship in making ends meet. While affordability provisions in the ACA may address some of the challenges that poor and moderate-income insured individuals face in affording medical care, it will be important to track ongoing financial barriers and financial instability even among those who have coverage. Early evaluation of premiums for plans in the Marketplace indicates that, for a 40-year old at 250% FPL, subsidized premiums in Missouri for the second-lowest cost silver plan ($193/month) and the lowest-cost bronze plan ($108/month) are at the median of plans analyzed across states.¹ Ongoing efforts may assess people’s other out-of-pocket costs and affordability of these expenses. Further, it will be important to monitor ongoing financial barriers among the poorest adults in the state, most of whom are left out of coverage expansions.

Adapting the Health System and Patterns of Care to Meet New Needs

Based on demonstrated need and barriers to care among the uninsured in Missouri prior to the ACA, health care providers may see increases in Missouri adults seeking care. Ultimately, the goal of coverage expansions under the ACA is to help people access needed health care services. Thus, once people gain coverage, providers and health systems will need to be prepared to serve newly insured people. Survey findings reinforce conclusions from prior research that gaining health coverage is likely to alter the way that people interact with the health system. Compared to their insured counterparts, uninsured Missouri adults face barriers to care, despite many having a demonstrated need. Some uninsured Missouri adults have ongoing health conditions yet still are not receiving regular care, and others have postponed preventive or other services, primarily due to cost. These findings indicate that there is likely to be some pent-up demand for health care services among Missouri’s newly-covered. However, survey findings indicate that barriers to seeking care, such as difficulty traveling to a provider’s office, may continue to persist among insured adults, particularly Medicaid beneficiaries. Outreach and education may be needed to link the newly-insured to a regular provider and help them establish a pattern of regular preventive care. In addition, efforts to ensure access to care for those who do have Medicaid coverage will be important to continue.

Changes in insurance coverage may lead people to use new or different providers, but clinics and health centers will continue to serve Missouri’s vulnerable populations. Many are concerned about shifting patterns of care under the ACA, as changes where people receive care may alter revenue streams for providers. The effect of changing revenue streams for different types of providers is unclear at this point. Based on the survey findings, uninsured Missourians are likely to have more options for where to receive their care once they obtain coverage under the ACA. Compared to their insured counterparts, prior to the ACA, they were more likely to seek care in clinics and to report that finances drove their decisions about where to seek care. As people gain Marketplace coverage, they may shift their service locations to more closely resemble that of people who had Medicaid or private coverage prior to the ACA, respectively. Clinics and health centers are likely to continue to see a substantial share of the low-income population, and these providers also may continue to see high levels of the uninsured, particularly in rural areas.

As implementation unfolds, Missouri providers may continue to be on the front lines of not only service delivery but also outreach and enrollment. Providers are one avenue that policymakers are using to reach out to uninsured adults who may be eligible for coverage expansions under the ACA. Survey findings indicate that emergency rooms and hospitals may be promising avenues for reaching eligible individuals who have episodic interactions with the health system, and community health centers can reach a share of the uninsured that use them for ongoing care.

Moving Forward in ACA Implementation

As of January 2014, about 54,000 Missourians had enrolled in coverage, and about 83% of these people were eligible for financial assistance.² However, this only represents about 8% of the population eligible for Marketplace coverage. ³ Recent developments in the state indicate that lawmakers are open the possibility of an expansion, possibly in a non-traditional manner. As more states, such as Arkansas, move forward with an expansion through a waiver, Missouri may consider that option. The health care community in Missouri supports an expansion and will likely continue to lobby for this change within the state. The uninsured reported a desire to gain coverage, particularly Medicaid, in the past five years, so the desire to enroll in coverage exists among the uninsured. As the open enrollment period comes to a close and many are left without coverage, the needs of the remaining uninsured may rise to the top of the policy agenda.

As enrollment in new coverage options grows and people begin to use their coverage, survey findings point to several issues that can inform ongoing efforts to implement the ACA. Future reports using the 2013 Kaiser Survey of Low-Income Americans and the ACA will continue to delve into these issues and provide state-specific findings, and future surveys can assess whether and how coverage, access, and family finances change under the law.