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

III. Gaining Coverage, Getting Care

How New Insurance Coverage Could Change How Missourians Use Health Care

Uninsured adults in Missouri generally do not seek or receive health care services at the same rate as insured adults, even when they have a need for care. Many uninsured adults have substantial health care needs that are not monitored by a physician. Cost is the main reason uninsured Missourians do not receive care when needed, and many lack a regular provider to facilitate follow-up or ongoing care. When uninsured adults do receive care, they often have limited options. As coverage expands under the ACA, uninsured adults are likely to get care more frequently and establish relationships with providers, yet many uninsured adults will remain without a coverage option and continue to have unmet needs for care.

A large segment of the uninsured in Missouri has little or no connection to the health care system.

While some uninsured adults in Missouri did report receiving health care services, most reported few connections to the health care system. Slightly more than half of uninsured adults in Missouri (55%) report that they have a usual source of care, or a place to go when sick or need advice about their health (not counting the emergency room). Having a usual source of care is an indicator of being linked in to the health care system and having regular access to services. In comparison, nearly all insured adults in Missouri —86% of those with employer coverage, 79% of those with nongroup coverage, and 84% of those with Medicaid coverage— have a usual source of care (Figure 12). In addition, uninsured adults in Missouri are less likely to have a regular doctor at their usual source of care, with 36% of uninsured adults reported having a regular doctor, about half the rate of insured adults. Notably, poor uninsured adults in Missouri, those that will likely remain uninsured under the ACA, are the least likely to have a usual source of care or a regular physician (Table 3).

Table 3: Share of Adults in Missouri with Usual Source of Care or Regular Provider, by Income and Coverage
	Uninsured		Insured
			Employer	Nongroup	Medicaid
Has a usual source of care^
All	55%		86%*	79%*	84%*
By Income
<100% FPL	49%		62%	—	84%*
100-400% FPL	59%		87%*	76%*	82%*
>400% FPL	—		88%	—	—
Has a regular provider at usual source of care1
All	36%		78%*	65%*	73%*
By Income
<100% FPL	24%		54%*	—	72%*
100-400% FPL	42%		77%*	60%	74%*
>400% FPL	—		83%	—	—
NOTES: Don’t Know and Refused responses not shown. “–“: Estimates with relative standard errors greater than 30% are not provided. ^4% of adults who report the emergency room as their regular source of care are reclassified as not having a usual source of care. Excludes people covered by other sources, such as Medicare, VA/CHAMPUS, or other state programs. *Estimate is statistically significantly different from uninsured estimate at the 95% confidence level. SOURCE: 2013 Kaiser Survey of Low-Income Americans and the ACA.

This lack of a connection to the health care system leads many uninsured adults in Missouri to go without care. Six in ten uninsured adults in Missouri (60%) reported a health care visit—including hospital visits, doctor’s office or clinic visits, mental health services, or trips to the emergency room— in the past year, compared to 93% of Medicaid beneficiaries, 87% of adults with employer coverage, and 78% of adults with nongroup (Figure 13). This pattern holds across all income groups. Of particular concern is the lack of preventive visits among uninsured adults in Missouri. Three in ten (28%) of uninsured adults reported a preventive visit with a physician in the last year, compared to 75% of adults with employer coverage and 73% of adults with Medicaid (data not shown).

The survey findings reinforce conclusions based on prior research: having health insurance affects the way that people interact with the health care system, and people without insurance have poorer access to services than those with coverage.^1,2,3 Thus, gaining coverage is likely to connect many currently uninsured adults in Missouri to the health care system. However, outreach may be needed to link the newly-insured to a regular provider and help them establish a pattern of regular preventive care. In addition, resources may be needed to reach out to the remaining uninsured in Missouri—including those who are in the coverage gap —to link them to the health care system and help them obtain preventive and acute health care services despite not having health insurance coverage.

Many uninsured Missourians have health needs, many of which are unmet or are being met with difficulty.

Missourians who lack health insurance still have health care needs. Nearly four in ten (38%) uninsured adults reported an ongoing health condition, compared to 21% with nongroup, and 67% with Medicaid (Figure 14). The lower percentage of adults with nongroup coverage reporting an ongoing health condition, compared to those with Medicaid or employer coverage, may reflect the ability of insurance companies to deny coverage to people with pre-existing health conditions prior to the ACA.⁴ In contrast, Medicaid beneficiaries are most likely to report having an ongoing health condition of all coverage groups, which reflects Medicaid’s role in caring for people with substantial health needs, such as individuals with disabilities or people who become impoverished due to high health care expenses. These findings hold across income groups (Table 4).

Table 4: Health Status of Missouri Adults, by Income and Coverage
		Uninsured		Insured
				Employer Coverage	Nongroup	Medicaid
Fair or Poor Overall Health	All	31%		10%*	—	52%*
	By Income
	<100% FPL	37%		—	—	57%*
	100-400% FPL	27%		14%*	—	—
Fair or Poor Mental Health	All	19%		7%*	—	40%*
	By Income
	<100% FPL	23%		—	—	41%*
	100-400% FPL	16%		9%	—	37%*
Have ongoing health condition that needs to be monitored regularly or needs regular care	All	38%		41%	21%*	67%*
	By Income
	<100% FPL	31%		27%	—	70%*
	100-400% FPL	41%		38%	16%*	63%*
Take prescription medication on regular basis^	All	30%		49%*	37%	74%*
	By Income
	<100% FPL	21%		29%	—	73%*
	100-400% FPL	34%		47%*	34%	77%*
NOTES: Don’t Know and Refused responses not shown. Excludes people covered by other sources, such as Medicare, VA/CHAMPUS, or other state programs. “–“: Estimates with relative standard errors greater than 30% are not provided. ^Excludes birth control.*Estimate statistically significantly different from uninsured estimate at the 95% confidence level. SOURCE: 2013 Kaiser Survey of Low-Income Americans and the ACA.

While uninsured Missourians with an ongoing health condition are more likely than those without to report receiving services (Figure 15), they are still less likely than their insured counterparts to receive care. While less than half (48%) of uninsured adults without an ongoing health condition say they received health care services in the last year, more than three-quarters (79%) of uninsured adults with a health condition received health care services. However, this rate is still lower than adults who have a health condition and have employer coverage, nongroup coverage, or Medicaid, nearly all of whom (99%, 98%, and 98%, respectively) reported receiving medical services over the course of the year.

When uninsured Missourians do receive care, they sometimes receive free or reduced-cost care, though the majority does not. Among adults in Missouri who reported that they received a health care service in the past year, 37% of uninsured adults in Missouri reported receiving free or reduced cost care, versus just 3% of those with employer coverage (Figure 16). Notably, 36% of adults with Medicaid who received services reported that they received free or reduced cost care. They may have done so during a period of uninsurance in the previous year or may associate the fact that they pay little or no costs when they see a provider as receiving “free or reduced cost” care. Uninsured adults in Missouri who received care were much more likely than their insured counterparts to be asked to pay up front for care: almost one-third (32%) reported being asked to pay for the full cost of medical care (not counting copayments) before they could see the doctor or provider, compared to just 11% of those with employer coverage and 18% of adults with Medicaid.  Again, adults with employer coverage or Medicaid may have experienced these issues during a period in the past year when they lacked coverage or when using a service not covered by their insurance.

Although some uninsured and insured adults in Missouri reported receiving free or reduced cost health care services, a larger share reported an unmet need for care. More than half (56%) of the uninsured and Medicaid (54%) beneficiaries in Missouri reported needing but postponing care, compared to 27% of adults with employer coverage and 25% with nongroup, and this pattern holds across income groups (Figure 17).

The most common reason for postponing care among uninsured Missourians is cost (89%). Adults with employer coverage (57%) or Medicaid (59%) are less likely to report cost as a reason for postponing care because presumably their insurance pays most or all of that cost (Figure 18). However, adults with employer coverage or Medicaid may report postponing care due to cost if their health insurance does not cover a specific treatment that they need. Appointment availability was also reported as a significant reason for postponing care. Almost half of adults with Medicaid (49%) reported postponing care because they could not get an appointment soon enough compared to 28% of adults with employer coverage, and 16% of uninsured adults. Adults with employer coverage were twice as likely as uninsured adults to report the office not being open when they could get there as a reason for postponing. Many physicians do not have hours outside of the normal workday, so some working adults may need to take time off to get care.

Adults with Medicaid were more likely than uninsured adults to report that they postponed care because they had difficulty traveling to the doctor’s office or clinic or that they could not get an appointment soon enough. These issues may reflect problems with provider participation in Medicaid, limits on Medicaid coverage of transportation services, or transportation barriers unique to the low-income population (such as not having a car). Poor and moderate-income adults may also experience access challenges due to difficulty getting time off from work or obtaining childcare for the time when they are at the provider.

Given the health profile of currently uninsured adults in Missouri, there is likely to be some pent-up demand for health care services among the newly-covered. Health systems may see increases in adults seeking care and will need to prepare for the newly insured. As people gain coverage under the ACA, the cost barriers to health care services will be reduced, but other barriers such as transportation or wait times for appointments may remain. Low rates and low provider participation, may pose a challenge for newly-insured individuals’ ability to find a provider to treat them.^5,6 In addition, it is important to bear in mind continuing access barriers among the population that remains uninsured under the ACA. As resources and attention shift to the newly-insured population, individuals left out of coverage expansions (such as poor adults) will continue to have health needs. The ACA included funds to expand service capacity in medically underserved areas, including expansion of community health centers, nurse-managed health centers, and school-based clinics. To meet the health care needs of both insured and uninsured individuals, it is important that these systems develop flexible treatment times and new models of care to accommodate people’s availability and expand capacity in areas where poor and moderate-income individuals reside or seek care.

Many uninsured Missourians reported limited options for receiving health care when they need it.

Uninsured adults in Missouri are less likely than their insured counterparts to receive care in a private physician’s office, but a physician’s office is the primary location for receiving care. Four in ten (40%) uninsured Missouri adults who have a regular source of care reported that it is a physician’s office or HMO, compared to over three-quarters (79%) of adults with employer coverage and 60% of adults with Medicaid (Figure 19). Almost one in three (28%) of uninsured adults in Missouri who have a regular source of care reported clinics or health centers as their usual source of care, almost three times as high as adults with employer coverage (10%). Notably, 12% of uninsured adults in Missouri reported the emergency room as their usual source of care – substantially higher than adults with private insurance, but lower than the rate for uninsured adults nationwide (data not shown).⁷

Uninsured and Medicaid adults in Missouri are more likely than other adults to report that they have limited options for their usual source of care. Among people with a usual source of care, 31% of the uninsured reported that they chose their usual source of care because it is affordable, compared to 4% with employer coverage (Figure 20). Adults with employer coverage are more likely to choose a site of care based on the ability to see their preferred provider compared to uninsured adults. Most of those who say they chose their usual source of care based on cost chose to go to a clinic or health center, reflecting the fact that these providers often have a mission to serve low-income populations and offer services with sliding scale fees.⁸

Based on the experience of their insured counterparts, the uninsured in Missouri may have more options for where to receive their care once they obtain coverage under the ACA. Specifically, as people gain insurance coverage, they may be less likely than those without coverage to choose a usual provider based on cost; thus, they may feel they have more options for where to receive their care. However, the large rural population and lack of providers may continue to limit the ability of insured and uninsured adults to receive care. While physicians are the leading source of care for adults in Missouri, clinics and health centers may play an important role in serving the poor and moderate-income population even once they gain insurance. They will also continue to serve an important role in caring for the remaining uninsured population, particularly those left out of coverage expansions. Providers and hospitals will also likely serve as an important resource for educating the uninsured and enrolling those who are eligible for coverage. Many of these providers offer services at reduced or sliding scale cost and will be the only option for people who have no insurance to help cover the cost of their care. Last, some Missourians who have relied on emergency rooms or urgent care centers as their usual source of care may require help in establishing new patterns of care and navigating the primary care system.