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candidate, who campaigned on a promise to repeal Obamacare (President Trump has continued to push for the ACA to be repealed and replaced, but Republicans in Congress have not agreed on the specifics of replacement yet).
Yet, despite Trump’s popularity in Missouri, the Show Me State has seen healthcare access improvements on par with the national average since the Affordable Care Act took effect. Missouri did not accept federal funding to expand Medicaid, so the impact on the state’s uninsured rate has not been as dramatic as it would have been if Medicaid had been expanded. But HHS reported that 203,000 people in Missouri gained health insurance coverage from 2010 to 2015 as a result of the ACA.
Missouri health ratings
Missouri ranked 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, but slightly lower — at 37th — in 2016. Missouri ranked 31st in the nation for lack of insurance, and 46th in terms of public health funding (dollars per person).
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’s uninsured rate, according to U.S. Census data, was 13 percent in 2013. It fell gradually over the next two years, to 11.7 percent in 2014 and 9.8 percent in 2015.
The overall uninsured rate in the U.S. was only slightly lower in 2015, at 9.4 percent. But it had started at a higher level than Missouri, with 14.5 percent of the U.S. population uninsured as of 2013. So the drop in the uninsured rate was sharper nationwide than it was in Missouri. (a 35 percent reduction, as opposed to a 25 percent reduction in Missouri)
MO’s 2017 exchange rates, plans
Four insurers offer plans through Missouri’s exchange in 2017. Most of the state’s counties have just one insurer offering plans, but those tend to be rural counties. The majority of the state’s population lives in counties that have at least two insurers offering plans in the exchange. The following insurers are offering coverage in Missouri’s exchange in 2017:
- Blue Cross Blue Shield of Kansas City
- Healthy Alliance Life (Anthem BCBS)
Missourians covered by 2016 Coventry plans purchased through the exchange had to select different coverage for 2017, as the company is only offering off-exchange plans in 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 was 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 2016 open enrollment period, there were 290,201 Missouri residents enrolled in private plans through the exchange.
Enrollment declined in 2017, however, by almost 16 percent. 244,382 people enrolled in coverage through the Missouri exchange between November 1, 2016 and January 31, 2017 (the 2017 open enrollment period) including new and renewing enrollees.
Nationwide, HealthCare.gov enrollments declined by about 5 percent, although state-run exchanges saw a small increase in enrollment for 2017. The Trump Administration cut back on advertising and outreach for HealthCare.gov in the final week of 2017 open enrollment, and the uncertainty surrounding the future of the ACA is also linked to the drop-off in enrollment.
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, and has consistently voted against the ACA and similar reform measures, and in favor of bills that would unravel the ACA.
Missouri’s U.S. representatives voted 6-3 against the ACA in 2010. Missouri has since lost a House seat, and as of 2017, Republicans have a 6-2 majority .
Republicans hold strong majorities in both the Missouri House and Senate. Former Governor Jay Nixon, a Democrat, 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.
In 2016, Former US Navy SEAL Eric Greitens (a former Democrat, now a Republican), won the gubernatorial election in Missouri, and took office in January 2017 (Nixon was term-limited and couldn’t run). Greitens has said that he opposes Medicaid expansion because of the cost to the state; states have to pay 5 percent of the cost from 2017 to 2019, and 10 percent thereafter, assuming the structure of the ACA remains unchanged.
Medicaid expansion in Missouri
Missouri rejected Medicaid expansion under the ACA, turning down federal funding that would have paid the full cost of expansion from 2014 through 2016. The state’s decision leaves about 96,000 individuals – 19 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 in Medicaid increased by 16 percent from late 2013 to November 2016.
A 2017 bill, S.B.70, would expand Medicaid in Missouri effective January 2018, but it’s unlikely to be enacted.
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.
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. 29 percent selected Medicare Advantage over traditional Medicare in 2016, slightly lower than the 31 percent who did 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 in 2015. 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: