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

Introduction

In January 2014, the major coverage provisions of the 2010 Affordable Care Act (ACA) went into full effect in Missouri and across the country. These provisions include the creation of a new Health Insurance Marketplace where moderate income families can receive premium tax credits to purchase coverage and, in states that opted to expand their Medicaid program, the expansion of Medicaid eligibility to low-income adults. In Missouri, the federal government is operating the Marketplace, as the state opted not to run its own. In addition, as of March 2014, Missouri had not expanded its Medicaid program, known as MO HealthNet, leaving many poor uninsured adults in Missouri who would have been newly-eligible for Medicaid without a coverage option (referred to as the coverage gap). However, there is no deadline for states to opt to expand Medicaid, and Missouri may choose to do so at a later date, expanding the potential of the ACA to reach many of the 800,000 uninsured Missourians.

Though ACA implementation is underway and people are already enrolling in coverage, policymakers continue to need information on the uninsured population. Reports of difficulties in enrolling in coverage, continued confusion and lack of information about the law point to challenges in the early stages of implementation, and information about the population targeted for coverage expansion can inform efforts to address these difficulties. In addition, because Missouri could still opt to expand its Medicaid program, it is important to have detailed data on the population that could benefit from such a coverage expansion. Specifically, information on poor and moderate–income adults’ experiences with health coverage, current patterns of care, and family situations can provide insight into some of the challenges that are arising in the first months of coverage and highlight the potential impact of gaining coverage on poor and moderate- income adults.

Based on findings from the 2013 Kaiser Survey of Low-Income Americans and the ACA, this report provides a snapshot of health insurance coverage, health care use and barriers to care, and financial security among insured and uninsured adults in Missouri at the starting line of ACA implementation and discusses how these findings can inform early implementation. The survey, conducted between July and September 2013, is a nationally representative survey that also includes a state-representative sample of over 1,800 nonelderly (ages 19-64) adults in Missouri. It was designed to focus on people targeted for financial assistance under the ACA and includes nonelderly adults with low incomes (< 138% FPL, or about $27,000 for a family of three in 2014) or moderate incomes (139-400% FPL, between approximately $27,000 and $79,000 for a family of three), as well as a comparison group with incomes over 400% FPL. Since Missouri has not expanded Medicaid coverage to adults with incomes <138% of FPL, we chose to present the findings among adults with incomes <100% FPL (most of whom will fall into the “gap population” that is ineligible for subsidies or coverage), or about $20,000 for a family of three in 2014, 100%-400% FPL (Marketplace subsidy eligible), and >400% FPL to better reflect coverage eligibility of uninsured Missouri adults.

The survey includes adults with employer coverage, nongroup, Medicaid, and other sources of coverage, as well as those with no health insurance. The Missouri component of the survey and report on its findings complements a report on similar findings for the nation.¹ This survey and report provides new data to help policymakers further understand early challenges in implementing health reform and assist outreach and enrollment workers, health plans, and providers and health systems. The survey also provides a baseline for future assessment of the impact of the ACA on health coverage, access, and the financial security of poor and moderate-income individuals in Missouri. A detailed explanation of the methods underlying the survey and analysis is available in the Methods section of the report.