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

Why are people still uninsured and what are their coverage options?

About half of the low-income uninsured report trying to obtain health insurance under the ACA in 2014, demonstrating that many in this population desire to be insured. The majority of this group is ineligible for coverage through their employer. Without Medicaid expansion, the only remaining option for many low-income uninsured is purchasing insurance without any subsidies to offset the cost. Consequently, it is not surprising that cost is the major reason that the low-income uninsured remain uninsured.

The majority of the low-income uninsured remain uninsured because they find coverage to be too expensive. The ACA aimed to make coverage more affordable, but Medicaid expansion was a major part of the intended design. Without Medicaid expansion or subsidies for the Marketplace, the majority (65%) of low-income uninsured report that they are without insurance because of cost. A small share (7%) report that they are uninsured because they either opposed the ACA, prefer to pay the penalty, or feel they do not need insurance (Figure 16). Notably, low-income uninsured adults in Missouri were less likely to name a job-related reason for lacking coverage in 2014 compared to 2013: 10 percent cited a job-related reason for lack of insurance in 2014 compared to 26 percent in 2013 (data not shown).

Many low-income uninsured tried to obtain ACA insurance but either encountered difficulty or were told they were ineligible. Forty-six percent of the low-income uninsured tried to obtain Medicaid or Marketplace insurance, but many encountered difficulties. About seven in ten (71%) encountered difficulty with at least one aspect of applying (Figure 17). About two-thirds (67%) tried to apply using more than one pathway. About half (46%) tried to sign up using the healthcare.gov website, about half (46%) called the Marketplace 1-800 number, and more than half (57%) visited the MO HealthNet agency (Figure 18). Ultimately, however, these people remained uninsured, saying that they were told they were ineligible and that coverage was too expensive.  Interestingly, one in six (16%) of those who did apply said that their coverage was pending (Figure 19). Missouri has been working to resolve the backlog of Medicaid applications that accrued in 2014.¹

The majority of low-income uninsured report not having access to employer coverage and a plurality do not think they will gain coverage in 2015. Eight in ten (82%) of the low-income uninsured are ineligible for health insurance through their employer, either because they are unemployed, their employer does not offer coverage, or because they are ineligible for coverage. Only one in six (16%) were eligible for coverage through their employer, but remained uninsured (Figure 20). The low-income uninsured population’s inability to obtain coverage through an employer is reflected in their response to whether or not they were planning on obtaining coverage in 2015: only eight percent said they were planning on getting coverage through their employer. The plurality of low-income uninsured (42%) were not planning on obtaining coverage in 2015 (Figure 21). Open enrollment for 2015 Marketplace coverage ended February 15^th; while enrollment for Medicaid is ongoing, it remains limited to the levels in place before the ACA was enacted.