In recent weeks, states like Colorado, California and Oregon have been hit hard by advertising campaigns designed to let people know about their state-created health marketplaces. State health marketplaces are a central part of the Affordable Care Act, but information about Missouri’s health marketplace has been hard to find. And that’s not just because the state decided not to set one up.
Like in most states, Missouri’s health marketplace will be created by the federal government. But Missouri has gone far beyond most states to reject a marketplace. This has left Affordable Care Act supporters scrambling to get the word out and make the federal health program work.
Ten days before the start of health marketplace enrollment, members of Kansas City area nonprofits gathered in the downtown office of the Mid-America Regional Council. They compared notes on how to negotiate the complex rules set up for the health marketplace in Missouri. Melissa Robinson is President and CEO of the Black Healthcare Coalition. She says this is an unusual situation: nonprofits turning to each other for help without the assistance of state government.
“This is an interesting dynamic for the Black Healthcare Coalition. Somewhat unprecedented,” says Robinson. “It’s an interesting situation where you just have to depend on the feds for everything. Typically, you can go to the state level and kind of work some things out and try to figure out and work together. But this has been interesting for us.”
Mo. Voters Reject State Marketplace
When the President signed the Affordable Care Act in 2010, a lot people working for health nonprofits in Kansas City were optimistic. It seemed to promise easier access to insurance and financial assistance for those who couldn’t afford it. But it hasn’t been so popular with Missouri voters.
“Missourians have spoken out very clearly and plainly that they oppose Obamacare,” explains Missouri House Speaker Tim Jones.
In August of 2010, voters overwhelmingly passed Proposition C, which rejected key parts of the Affordable Care Act. The state ended up returning a grant of $21 million provided by the Department of Health and Human Services to set up a health exchange.
Ryan Barker of the Missouri Foundation for Health says, instead of $21 million Missouri only received about $1.8 million.
That money went to two groups that will fund "navigators" in Missouri — people who are trained to teach the public how to use the federally-created health marketplace.
“(It's) nowhere near enough money to help all the consumers that are going to need help understand what is this marketplace, how do I navigate it, how do I figure out my options,” Barker says of the $1.8 million.
The federal government has since come forward with more funding for awareness — about $3 million from the Health Resources and Services Administration, and Missouri will split $12 million with several other states. But funding problems have been just the start of the trouble for health marketplace supporters in Missouri.
Last year, voters overwhelming passed another ballot measure related to the Affordable Care Act. The summary of Proposition E stated that it forbid the Governor or any state agency from setting up or running a state health exchange. But if you read the full text of the bill, Proposition E actually did a lot more.
“There’s a provision in there that says no state agency, state employee, local political subdivision shall provide assistance or resources to the federal government in establishing an exchange,” says Andrea Routh, Executive Director of the Missouri Health Alliance.
Beyond just rejecting a state health exchange, Prop E prohibited state employees from doing any training or outreach for the federal exchange as well. And Prop E has teeth.
“A citizen or a legislator can file a lawsuit against a state agency or a state employee if they think they are violating the law,” explains Routh. “So if I happen to think that some bureaucrat in Jefferson City is helping the federal government set up an exchange, I could sue them.”
While Prop E’s prohibitions have been lessened a bit by more recent legislation, Routh says that fears over lawsuits have stopped most state groups from having any involvement in the health marketplace. For example, the Department of Elementary and Secondary Education had posted a web announcement from the U.S. Department of Education to let families know the health exchanges were coming. But concerns over a lawsuit led the Missouri Department to remove the notice.
“In legal terms, it has had a chilling effect,” says Routh.
Things got even more complicated last July when Missouri legislators passed a law containing state rules and licensing requirements for health marketplace navigators. The law also applies to certified application counselors, which are a kind of unfunded navigator for nonprofits. Critics of the law pointed out that navigators already needed to be licensed by the federal government. Andrea Routh says the rules provided by the state conflict with the federal rules.
“There’s another piece of the state law that says navigators cannot discuss the options outside the marketplace with the person who’s sitting there with them asking for assistance,” Routh says. “The federal law is counter to that and says you need to tell people there are other options for them. It’s not just the exchange or marketplace.”
There’s another wrinkle for the Affordable Care Act in Missouri. The national health plan offers health insurance subsidies for people and families whose income is between 100 and 400 percent of poverty. People living below that income level are supposed to be covered by expansions in state Medicaid programs. The federal government has offered to pay 100 percent of the first three years of expansion, gradually reducing funding after that. So far, Missouri has chosen not to expand Medicaid. Ryan Barker says that spells trouble for over 200,000 low income Missourians who don’t have insurance.
“They can go to the exchange, but they can’t get tax credits or subsidies,” explains Barker. “So they would be paying full price. We don’t think that is a reasonable option for them. They probably are not going to be able to afford that. And without Medicaid expansion, there really is nothing in terms of insurance coverage for those individuals.”
Fighting Off Obamacare
Critics of Missouri’s health care laws say they’re purposely complicating the health marketplace to derail the federal program. But Republican House Speaker Tim Jones doesn’t see it that way.
“As representatives of the state of Missouri, we’re simply following the wish of all Missourians,” says Jones.
Earlier this week on a conference call, Republican Lt. Gov. Peter Kinder expressed concerns over the affects the Affordable Care Act was having on businesses. He encouraged Missourians not to use the health marketplace.
“This law prescribes a one-size-fits-all plan for all of us. I would hope there would be a lot of active resistance to the implementation of this law and would say that there needs to be. So if you can – yes – resist signing up,” Kinder said.
While the state is still considering Medicaid expansion, many Republicans like Speaker Tim Jones believe it’s too expensive.
“As we look at how much government we should expand under the Obamacare options, we need to decide how much more of our budget to we want to put towards that,” says Jones
Despite the pushback, Affordable Care Act supporters continue to press on. Last Saturday, Health and Human Services Secretary Kathleen Sebelius spoke at a conference of state government employees at the Westin Crown Center Hotel. She urged states to expand their Medicaid programs and embrace health marketplaces.
“If the deal that currently is on the table for states around the country to expand Medicaid mostly on the federal dime was offered to me when I was governor of the state of Kansas,” Sebelius told the conference. “I would’ve jumped at the offer.”
Less than a week before the start of enrollment, many nonprofit workers like the Black Health Coalition’s Melissa Robinson are busy but hopeful.
“We’re optimistic,” says Robinson. “But we are in anticipation that there will be some bumps and maybe some hiccups, and so you hope for the best and plan for the worst.”
Missouri’s health marketplace enrollment is scheduled to begin on October 1.
Are you eligible for insurance subsidies under the Affordable Act Care? Find out with this tool.