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Missouri health insurance

‘Show Me State’ balks at Obamacare, but enrolls 74,000 in QHPs

Where a state ranks in health status and how its political leaders approach health care reform can impact your impression of what it’s like to live there. Use this review of national health rankings as well as selected ACA initiatives to get a feel for this part of life in Missouri.

Missouri health ratings

Missouri ranks 34th among the 50 states and the District of Columbia on the 2014 Scorecard on State Health System Performance produced by The Commonwealth Fund. Missouri improved one position since 2009. See how Missouri performed on about 40 health indicators that contribute to its overall ranking.

The United Health Foundation publishes America’s Health Rankings, and it ranked Missouri 39th, up one position since 2012. Missouri enjoys a high high-school graduation rate, little disparity in health status by level of education completed, and a relatively low rate of low birthweights. However, the positives are countered by a high smoking rate, a low immunization rate for children, a high incidence of cardiovascular disease, and a high rate of deaths related to cancer.

Additional public health information for Missouri is available in the 2014 edition of Trust for America’s Health.

Do you want to see how a particular county in Missouri scores on health measures? Visit the county-level comparisons compiled by Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.

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 U.S. Senate vote on the ACA in 2010, Sen. Claire McCaskill-D voted “yes,” while Sen. Christopher Bond-R 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.

How did the ACA help Missouri?

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 mid-2014, it had decreased slightly to 15.1 percent.

In 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), the average decrease was 2.2 percentage points for an average uninsured rate of 16.5 percent.

Missouri enrollment in QHPs

During the ACA’s 2014 open enrollment period, 152,335 Missourians selected a qualified health plan (QHP). That’s 23.2 percent of the estimated eligible market according to the Kaiser Family Foundation. Nationally, 28.0 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.

Anthem Blue Cross and Blue Shield of Missouri and Coventry sold policies through the marketplace for 2014. Both are expected to participate again for 2015. However, it is unlikely any information about next year’s rates will be available until 2015 open enrollment begins. Unlike most other states, Missouri does not have authority to review insurer’s pricing.

Medicaid expansion in Missouri

Missouri rejected Medicaid expansion for 2014, and a Kaiser Family Foundation study estimates 283,000 Missouri residents are excluded Medicaid coverage as a result. The same study estimates that 193,000 people in Missouri are in the Medicaid coverage gap. Those in the gap don’t qualify for Medicaid, yet they don’t make enough to qualify for federal subsidies that would help them purchase individual coverage through the marketplace.

Missouri’s existing Medicaid 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.

Based on the state’s existing criteria, 45,513 Missourians qualified for Medicaid or CHIP during the 2014 ACA open enrollment period.

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.  During an MHIP board meeting in December 2013, it was reported that the transition was working well and was on schedule or even ahead of schedule.

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.

In 2014, CO-OPs operated in 23 states. Three CO-OPs are expanding into neighboring states in 2015. See where CO-OPs were launched. Missouri does not have a CO-OP.

State-based health reform legislation

Here’s a summary of recent Missouri legislation related to healthcare reform: