Missouri resisted the implementation of the Affordable Care Act, opting for a federally facilitated exchange and declining Medicaid expansion. The state favored Trump in the 2016 presidential election, with 57.1 percent of its voters choosing the Republican candidate turned president-elect, who promises to repeal Obamacare
Yet, The Show Me State has seen healthcare access improvements on par with the national average since the Affordable Care Act took effect. With 2017 open enrollment underway as of November 1, we have yet to see how limited plan options—most Missouri counties will only have one carrier, rising premium rates, and the new administration could impact 2017 enrollment. We’ve answered some common questions about the “Trump effect” on healthcare coverage here.
Missouri health ratings
Missouri ranks 36th among the 50 states and the District of Columbia on The Commonwealth Fund’s 2015 Scorecard on State Health System Performance. Indicators in five categories determined this score: Access, Prevention & Treatment, Avoidable Hospital Use & Costs, Healthy Lives, and Equity.
The state fared just below the U.S. average for its percentage of uninsured adults (16 percent) and children (7 percent) and just better than average for adults who went without care due to cost in the past year (14 percent). For additional details on how Missouri performed, see its Scorecard.
The United Health Foundation publishes America’s Health Rankings, and it also ranked Missouri 36th in 2015. Again, the state performed near the middle in measures related to access: 28th for primary care physicians, 28th for disparity in health status, and 29th for lack of insurance.
Additional public health information for Missouri is available in the 2014 edition of Trust for America’s Health. Visit the county-level comparisons compiled by Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.
How has Obamacare helped Missouri?
Missouri is among states less accepting of the Affordable Care Act. And, like other states that have not embraced the ACA (i.e., have not implemented a state-run marketplace or expanded Medicaid, or have only implemented one of those measures), it has seen more gradual reductions in its uninsured population.
Missouri saw little change in its uninsured rate over the course of the ACA’s first open enrollment period. In 2013, the state’s uninsured rate was 15.2 percent. By the end of 2014, it had decreased to 13.4 percent.
As of late 2015, Missouri was 10th among states with the smallest reductions in uninsured. Its uninsured population decreased 3.6 percentage points from 15.2 in 2013 to 11.6 in 2015. Nationwide, the uninsured rate fell from 17.3 percent o 11.7 percent in the same timeframe.
MO’s 2017 exchange rates, plans
Four carriers continue to offer plans through Missouri’s exchange in 2017, though many counties will only have one carrier option:
- Blue Cross Blue Shield of Kansas City
- Healthy Alliance Life (Anthem BCBS)
Missourians covered by 2016 Coventry plans purchased through the exchange will need to select different coverage for 2017, as the company will only offer off-exchange plans for 2017.
Missouri enrollment in qualified health plans
During the ACA’s 2014 open enrollment period,152,335 Missourians selected a qualified health plan (QHP) from the state’s Obamacare exchange. That’s 23.2 percent of the estimated eligible market according to the Kaiser Family Foundation. Nationally, 28 percent of the estimated eligible market enrolled in QHPs during 2014 open enrollment. Eighty-five percent of Missouri residents who enrolled in a QHP qualified for subsidies that made their premiums more affordable.
As in most states, Missouri’s exchange enrollment picked up by 2016. At the end of the last open enrollment period, there were 290,201 Missouri residents enrolled in private plans through the exchange.
Missouri and the Affordable Care Act
Missouri has balked at the Affordable Care Act. It refused to implement a state-run marketplace, rejected Medicaid expansion, and passed a law to restrict consumer assistance; however, a court ruling blocked enforcement of the law.
In the 2010 U.S. Senate vote on the ACA, Sen. Claire McCaskill, a Democrat, voted “yes,” while Sen. Christopher Bond, a Republican, voted “no.” Republican Sen. Roy Blunt has replaced Bond in the Senate. Blunt voted against the ACA as a U.S. representative from Missouri in 2010.
Missouri’s U.S. representatives voted 6-3 against the ACA in 2010. Missouri has since lost a House seat, and Republicans have gained a 6-2 majority.
Republicans hold strong majorities in both the Missouri House and Senate. Democratic Gov. Jay Nixon supported a state-run health insurance marketplace. However, state legislators did not authorize a state-run marketplace and, in fact, passed legislation to prevent Nixon from doing so by executive order. Similarly, Nixon supported Medicaid expansion, but a majority of state legislators did not.
Medicaid expansion in Missouri
Missouri rejected Medicaid expansion for 2014. The state’s decision leaves about 109,000 individuals – 21 percent of the state’s uninsured population – in what is known as the coverage gap. Despite the state’s decision not to expand Medicaid, monthly average enrollment improved slightly from 2013 with a 14 percent change by June 2016.
Missouri Medicaid’s existing eligibility criteria for adults are quite restrictive. Non-elderly, non-disabled Missourian adults without children are not eligible for Medicaid. Adults with dependent children qualify for Medicaid only if the family’s income is 24 percent or less of the federal poverty level (FPL).
Missouri infants (1 year old and younger) qualify for Medicaid if family income is 196 percent of less of FPL. Children ages 1 through 18 years old qualify if family income is 150 percent or less of FPL. Children qualify for the Children’s Health Insurance Program (CHIP) if family income is between 300 percent FPL and Medicaid’s upper limit.
Visit the Missouri Department of Social Services to learn about MO HealthNet (Medicaid) and MO HealthNet for Kids (CHIP).
Does Missouri have a high-risk pool?
Prior to 2014 and the ACA’s reforms to the individual health insurance market, coverage was medically underwritten in nearly every state, including Missouri. Since a review of medical history was part of the application process, people with pre-existing conditions often found themselves unable to purchase comprehensive coverage in the private market.
The Missouri Health Insurance Pool (MHIP) was created in 1991 to provide health insurance for people who were denied coverage in the private market because of their medical history. But medical history is no longer an eligibility factor for private health insurance, making high-risk pools largely unnecessary now that the ACA has been implemented.
In 2013, the Missouri legislature passed SB262, which allowed MHIP to cease operations on January 1, 2014, and transition members to coverage in the private market instead.
Other ACA reform provisions
The Affordable Care Act created a loan program to encourage the formation of a new type of health insurer, called a Consumer Operated and Oriented Plan (CO-OP). CO-OPs are not-for-profit and customer-directed. They are intended to increase market competition and consumer choice.
Medicare enrollment in the state of Missouri
Missouri Medicare enrollment reached 1.1 million in 2015, about 19 percent of the state’s population and slightly higher than national enrollment (17 percent). About 81 percent of Missouri Medicare beneficiaries qualify based on age alone, while 19 percent are on Medicare as the result of a disability.
Missouri’s Medicare recipients can select a Medicare Advantage plan instead of Original Medicare if they wish to receive additional benefits. Twenty-eight percent selected Medicare Advantage over traditional Medicare in 2015, slightly lower than the 31 percent who do so nationwide.
Likewise, Medicare beneficiaries may also select a Medicare Part D plan to gain stand-alone prescription drug coverage, and 47 percent selected these Rx plans. Nationwide, 45 percent of Medicare recipients enrolled in Part D plans.
Historically, Medicare has paid about $8,924 annually per Missouri enrollee. The state ranks 16th in overall Medicare spending with $9.6 billion per year.
Here’s a summary of other recent Missouri legislation related to health reform: