Where a state ranks in health status and how its political leaders approach healthcare 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, a state that has resisted Obamacare.
Missouri health ratings
Missouri ranks 34th among the 50 states and the District of Columbia on The Commonwealth Fund’s 2014 Scorecard on State Health System Performance. 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 36th in 2014, up three positions from 2013. 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 teens, and a high rate of physical inactivity.
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 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.
How did Obamacare 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 the end of 2014, it had decreased to 13.4 percent. The state’s uninsured rate dropped an additional 2 percentage points to 11.4 by mid-2015, representing a total change of 3.8 percentage points since 2013.
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 5.3 percentage points for an average uninsured rate of 13.4 percent. As such, Missouri’s uninsured rate is slightly better than other states that have not implemented a state-run exchange and/or Medicaid expansion.
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.
By the end of 2015 open enrollment, 253,430 Missourians had selected a QHP – 101,095 more than the year prior. However, as happens, some dropped coverage or failed to make their premium payments. By June 30, effectuated enrollment was 212,256 people. Of these remaining enrollees, 88.7 percent were in a plan with an advanced premium tax credit, and 57.7 were receiving cost-sharing subsidies.
Three of Missouri’s exchange carriers requested double-digit rate increases for 2016: Blue Cross and Blue Shield of Kansas City, Coventry and Humana. Unlike most other states, Missouri does not have authority to review insurer’s pricing.
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 10 percent change by July 2015.
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 18.6 percent of the state’s population, slightly higher than the 17 percent of the U.S. population enrolled in Medicare. About 79 percent of Missouri Medicare beneficiaries qualify based on age alone, while 21 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-nine percent selected Medicare Advantage over traditional Medicare in 2015, slightly lower than the 32 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, 43 percent of Medicare recipients enrolled in Part D plans.
Historically, Medicare has paid about $9,724 annually per Missouri enrollee. The state ranks 16th in overall Medicare spending with $9.6 billion per year.
State-based health reform legislation
Early in 2015, Republican Sen. Bob Onder filed SB 51, a bill aimed at blocking the ACA’s individual mandate by revoking health insurance companies’ licenses to sell policies in Missouri if they accept federal subsidies for policies sold through the federal health insurance marketplace. The bill has not seen any progress since January 2015.
Here’s a summary of other recent Missouri legislation related to health reform: