Cathy Hattey, 59, a former factory worker from Warsaw, Mo., isn’t pinning her hopes for affordable health insurance on the online marketplace that opens Oct. 1.
Though the insurance exchange is supposed to bring down costs for people without job-sponsored coverage, it won’t help Hattey and an estimated 226,525 other uninsured Missourians. They make too little to qualify for government subsidies.
Yes, too little.
In a twist that wasn’t intended by the authors of the federal Affordable Care Act, most of Missouri’s poorest, working-age residents – those under age 65 and below the poverty line of $11,490 for an individual and $15,510 for a couple – aren’t eligible for government help.
They can’t get free or low-cost health coverage through Medicaid. Nor can they get federal tax credits to help pay for private insurance.
They fall in a coverage gap.
The tax subsidies that will be available through the exchange are intended to make private coverage affordable for people who make between the poverty level and four times that amount.
Under the Affordable Care Act, those making less than 138 percent of poverty – or about $32,500 for a family of four – were supposed to be covered by an expansion of Medicaid, the public insurance program for the poor.
But the U.S. Supreme Court ruled that the Medicaid expansion was optional for states. Missouri – and 26 other states – turned it down. As a result, a big swath of the uninsured will stay that way when new coverage options kick in Jan. 1.
Health care advocates who will counsel the uninsured during online sign-ups this fall say they aren’t sure what they'll say when no affordable option pops up on the computer screen.
“It’s going to be heartbreaking, because there’s just nothing” for people in the gap, said Ryan Barker, vice president for health policy at the Missouri Foundation for Health, a St. Louis-based nonprofit organization.
For example, people like Hattey, without children living at home, don’t qualify for Medicaid unless they are elderly or disabled.
“There isn’t anything I fall in the right slot for,” said Hattey, who struggles to buy supplies to manage her diabetes while she looks for a job. She said she and her husband, who live in Benton County in west-central Missouri, make about $1,100 a month from her housecleaning jobs and his part-time work unloading trucks at Walmart.
“I’m just unemployed and hope to find a job soon,” she said.
POLITICS OF MEDICAID
The coverage gap illustrates the polarizing debate over what role government should play in health care, who is truly needy and how to pay the bills.
After skirting the issue during his 2012 re-election campaign, Gov. Jay Nixon, a Democrat, pushed for the Medicaid expansion during the legislative session that ended in May. He cited the billions of federal dollars it would bring to the state, as well as the benefits of preventative care.
The federal government would shoulder the tab for the new participants the first three years, with the state’s share gradually rising to 10 percent by 2020.
Republican legislators rejected the plan, saying that the current Medicaid program was flawed and adding more participants was financially unsustainable. Legislative leaders appointed committees to suggest ways to make the $8.9 billion program more efficient and increase the personal responsibility of participants.
Sen. Gary Romine, R-Farmington, chairs the Senate interim committee on Medicaid Transformation and Reform. “With our budget as tight as it is, to add anyone else to the rolls only takes dollars away from another area,” he said. “So for us to find ways to cover those in need, we’ve got to find a way to come up with funds.”
An estimated 877,000 Missourians are uninsured.
While St. Louis and Kansas City have the largest concentrations, a study released by the Missouri Budget Project earlier this year concluded that many rural areas have higher percentages of uninsured adults.
For example, the study found, southeast Missouri would have seen its uninsured population drop by 31 percent if the expansion had passed, vs. a 26 percent drop in the St. Louis region.
The Budget Project, a nonprofit group that advocates for policies that help low- and moderate-income people, backs the Medicaid expansion.
The findings seemed “to really surprise the legislators,” said study co-author Tim McBride, a health economist at Washington University. “They seem to think the uninsured problem is an urban problem, not a rural problem, when it’s really the other way around, at least in terms of proportion.”
Small businesses predominate in some rural areas, and only about half of workers in small firms were offered health insurance in 2010, according to a study by the Commonwealth Fund, a private foundation that researches ways to improve access to health care.
SAFETY NET'S LIMITS
Medicaid, which covers more than 870,000 low-income Missourians, is geared to certain groups: seniors, people with disabilities, pregnant women and some families with children. There are different eligibility standards for each group.
For example, to be eligible, a nonelderly adult can earn no more than 19 percent of the poverty level and must have a dependent child. For a single mother with two children, that means an income limit of $3,711 a year.
“It’s the working poor, it’s the hourly wage-earners – making $7 to $15 an hour” who can’t qualify and wind up in the coverage gap, said Barker, who has traveled the state explaining the new federal health care law.
Count Jennifer Rosa, 40, of Ellington, Mo., in Reynolds County, in that group. She works full time at a grocery store, handling carry-out for customers and stocking shelves. The store doesn’t offer insurance to its employees.
Her son is on Medicaid – the cutoff is higher for children – and Rosa said she pays $75 a month for that. But she makes too much to be eligible herself.
“You get up every morning and pray you don’t get sick, don’t have a toothache, don’t need glasses,” she said.
About twice a year, her chronic bronchitis flares up.
“You just don’t go to the doctor,” she said. “You get sick and just tough it out.”
While she would like to have affordable insurance, she’s not a fan of the Affordable Care Act, dubbed Obamacare.
“I don’t like the idea of them forcing this down our throats,” Rosa said. She opposes subsidizing people who “sit at home and draw a check. I don’t want them to do everything for me, but as a working person, some help would be great. We’re people who work for a living.”
Crystal Eoff, 29, of Hillsboro, said she is just looking for stopgap coverage.
Eoff has been uninsured since she lost her job in the financial services industry last year. Her income comes mainly from substitute teaching while she works on a master’s degree to become a full-time teacher.
“I’m not disabled, I have no children, I’m an able-bodied working person, which I totally get,” she said. “But people like me are falling through the gap.”
Though she has no health problems, being uninsured “is scary,” Eoff said. “I was raised in a house where you always had car insurance, you always had health insurance.”
Still, some Republicans say helping “able-bodied adults” ranks low on their priority list.
Sen. Rob Schaaf, R-St. Joseph, said he’d rather raise the eligibility threshold for the elderly and disabled, who are capped at 85 percent of the poverty level – $9,767 for a single person.
“The people that really need it, who are not able to help themselves, we’re going to make them live at 85 percent of the federal poverty level. But the people who are able to help themselves, we’re going to let them live at 138 percent of the federal poverty level and subsidize their health care? Where’s the justice in that?” Schaaf asked.
SHOPPING ON THE EXCHANGE
Beginning Oct. 1, the uninsured can try shopping on the exchange through the federally run portal, www.healthcare.gov.
Some consumers might benefit from a little optimism. Here’s why:
The subsidies are based on estimated 2014 income. Thus, people below the poverty line could be eligible for subsidies if they projected that next year, their earnings would surpass the poverty level.
Often, their wages fluctuate anyway, depending on seasonal work and part-time jobs, said Kathleen Stoll, deputy executive director of Families USA, a health care advocacy group.
“We’re not encouraging people to grossly exaggerate their income,” she said. “We’re saying, ‘If you’re very close and you’re not sure how to estimate your income, you may want to … not make a conservative estimate and miss out on getting help.’”
Federal officials say the solution is to expand Medicaid, not fudge income figures.
“We’re asking people to honestly answer the questions,” said Nanette Foster Reilly, a senior administrator at the regional office of the Centers for Medicare and Medicaid Services.
Lacking insurance, people in the gap are likely to continue seeking care in emergency rooms, community health centers and walk-in drugstore clinics. Or go without.
“People are so confused about this,” said Washington University’s McBride. “They’re going to come in at 140 percent of the poverty line and they'll be able to get help. And somebody comes in at 80 percent of the poverty line and (counselors) are going to have to tell them, ‘You’re out of luck.’”
Romine, the senator heading the Medicaid committee, said he had no “good answer.”
“Until the dust settles with the exchange and the dust settles with what Medicaid is going to look like in Missouri, there’s still going to be a hole there.”