Health care regulation an obstacle to some Missouri residents' insurance enrollment

Monday, March 3, 2014 | 7:34 p.m. CST; updated 2:46 p.m. CST, Tuesday, March 4, 2014

COLUMBIA — Roughly 1 percent of Missouri residents have purchased a health insurance plan through the state marketplace. Researchers at George Washington University say the restrictions the state legislature placed on implementation of the Affordable Care Act could be a factor in the low enrollment.

Last year, the Missouri legislature passed the Health Insurance Marketplace Innovation Act, which defined the role of the marketplace "navigator" and required that people or organizations who fill the role be licensed.

The regulation initially deterred navigators somewhat, said Stephene Moore, regional director of the U.S. Department of Health and Human Services.

"It put up a little pause for some folks," Moore said.

Robin Corderman, a certified application counselor with Primaris, said the law requiring navigators to be licensed created "one more layer of bureaucracy."

And that might have been the goal — at least for some.

Last month, Sen. Kurt Schaefer, R-Columbia, sponsored SB 498, which would also require navigators to purchase a $100,000 bond as insurance in case they are sued for releasing a consumer's private information. Currently, if a navigator were to be sued and lose in court, he or she would be responsible for at least $50,000 in damages. Schaefer's bill is still under consideration.

New restrictions passed by the Missouri Senate, as reported by The Associated Press, includes requirements for navigators to take a written exam and undergo a criminal background check.

According to the Affordable Care Act, the job of a navigator is to:

  • educate members of the public about health plans available to them.
  •  distribute information about enrollment.
  •  help people enroll.
  •  refer people to the appropriate agency should they need to file a complaint.
  • perform these activities in a way that is "culturally and linguistically appropriate."

Those who perform the role of navigator might have a different title, such as "certified application counselor," and they are eligible to receive federal funding for their work. Navigators in Missouri have to pass an exam and pay a license fee, which is $25 for an individual and $50 for an organization.

Keeping enrollment down

A recent study by George Washington University found evidence that navigators in states with limited implementation of the Affordable Care Act struggle more to enrol people in plans. 

Researchers defined restrictive states by two policy choices: requiring licensing of navigators and failing to expand Medicaid. Missouri fits into both categories.

Health centers, defined as entities that serve communities where health care is scarce, in states with restrictive policies were less likely to help with overall plan enrollment, the study also found.

Of all health centers that participated in the study, about 65 percent of those in restrictive states notified patients of their eligibility for insurance programs. In states with less restrictive implementation of the Affordable Care Act, about 81 percent of health centers notified people of their eligibility.

Researchers in the study wrote that more than 10 percent of health centers in restrictive states thought at least three-quarters of their patients would remain uninsured.

Results of the study also found that health centers in restrictive states, such as Missouri, were less likely to:

  • get funding for outreach.
  • notify people of their eligibility.
  • provide paper applications.
  • monitor applications.

But Moore said she was confident navigators working in Missouri health centers have recovered from the inconvenience of having to get licensed.

"It's all been dispelled now, and we're moving forward," she said.

Contested law

Late last year, several organizations and individuals involved in assisting with enrollment in the federal health insurance program filed a lawsuit to keep Missouri licensing requirements from being enforced, alleging the law limited the ability of navigators to inform residents about different health care plans.

The federal law mandates navigators to give advice about details of particular plans and which are better or worse, but Missouri law requires an additional license to give this kind of guidance.

In a decision issued on Jan. 23, U.S. District Court Senior Judge Ortrie Smith concluded Missouri's licensing requirements conflicted with the federal law.

The future of the law is not clear. Missouri Attorney General Chris Koster's office filed a notice of appeal of the decision on Feb. 24, according to Nanci Gonder, press secretary for the Attorney General's Office.

Enrollment numbers

According to the Feb. 12 report on enrollment from the U.S. Department of Health and Human Services, fewer than 55,000 Missouri residents have enrolled in an insurance plan through the state's marketplace.

Census data from 2011 and 2012, as cited by the Missouri Foundation for Health, found that 16 percent of Missouri residents under age 65 were uninsured. That amounts to about 834,000 people without insurance.

"There's a big difference there," Moore said of the disparity between those enrolled to date and the number of Missourians who remain uninsured.

But she said the discrepancy could be due in part to a very human tendency.

"We Americans like to put things off to the last minute," Moore said. With the end of the open enrollment period fast approaching, Moore said she expects more people to be signing up in the coming weeks. Open enrollment ends March 31.

Moore said she expects the next enrollment report, due some time between March 10 and March 15, would show much higher numbers of people enrolled than reflected in the February report.

Another reason that many in Missouri will continue to go uninsured is the state's failure to expand Medicaid, Moore said. Many Missouri residents cannot afford subsidized insurance through the exchange but do not qualify for Medicaid under Missouri's current program either, she said.

Expanding Medicaid would make a dent in the number of uninsured residents, Moore said. More than 300,000 could be insured through Medicaid if the state were to seize the opportunity to expand the program, she said. The General Assembly has repeatedly refused to do so, though Gov. Jay Nixon has tried to keep the option alive.

Corderman echoed Moore's forecast that enrollment would pick up in the coming weeks. She said she expected a rush to get enrolled before the end of March.

Despite early problems, the marketplace's website is now functioning. And yet, people shopping for a plan need a lot of guidance, Corderman said. She has dealt with many people who have never had insurance before, and it was a difficult concept for them to understand.

To her own surprise, Corderman formed relationships with those she helped through the process of enrolling for an insurance plan, she said. The people she helped didn't disappear but returned with questions, bringing their friends and families to get help enrolling.

"I had not anticipated that," Corderman said.

Supervising editor is Katherine Reed.

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Michael Williams March 4, 2014 | 8:32 a.m.

Yeah, blame it on "regulations". That's the ticket. Get your excuses out now.

The sentence "And that might have been the goal — at least for some" tells me this is more an editorial than "news".

Missourian: Your reporting on implementation and ramifications (for Columbians) of the ACA is absolutely pathetic, regardless which side you happen to advocate. You are publishing crap, nothing important that folks want or even need to know.

(Report Comment)
Christopher Foote March 4, 2014 | 9:28 a.m.

Here's a chart illustrating enrollment percentages by state:
States are color coded red or blue based on the last presidential election (and are thus a good proxy for who controls the state legislature and implementation of state health insurance marketplaces). Notice any trends in the distribution of red and blue states? Perhaps you care to argue that the distribution is random? If not, what accounts for the disparity? The Missourian's answer, punitive regulation, seems reasonable. How would you prefer the Missourian to report this story, ignore it? That would be a disservice to their readers. I think it is newsworthy that a major political party has no interest in good governance, and is actively thwarting the working poor from acquiring health insurance (which I might add the government is providing for you at considerable tax payer expense).

(Report Comment)
Christopher Foote March 4, 2014 | 9:45 a.m.

Just to clarify, the governemnt is subsidizing your health care. If you turned 65 in 2010, lifetime medicare taxes for the average couple were $61,000 and lifetime medicare benefits were $180,000, which is roughly a $100,000+ subsidy. Data from here:
Depending on age and salary the benefits and costs will vary, however in the aggregate the government is spending far more than it is taking in. Note the ACA attempts to address this by limiting medicare spending. The "anti-entitlement/small government" crew labeled this Death panels. Would it be scurrilous for the Missourian to reveal that as well?

(Report Comment)
Michael Williams March 4, 2014 | 9:50 a.m.

Chris: Oh, it's political as hell, all right.

Some folks don't like the interference, and they don't like the chaos that's been created in their lives. That's PURE politics. So, we are in agreement on that. Where we AREN'T in agreement is that you believe this is about the race of the President. I believe it's about a redistribution philosophy that runs counter to every citizen with a lifelong habit towards self-sufficiency.

The Missourian ignore it? Well, hell....the Missourian has been ignoring ACA stories from the get-go. Just ask them "Where are the interviews of students, medical office administrators, doctors, hospital administrators, and ordinary citizens? Where are the real-life interpretations of the law and the impacts upon Columbia and its citizens?"

No, this newspaper is not a newspaper. It's an advocacy rag, with advocacy themes chosen by the faculty and cause-du-jour of the supporting students.

So, don't tell me about "disservice". I already know "disservice"....each and every time a day goes by without the Missourian doing its job.

As for good governance, I think the poorest governance is the kind that places citizens in permanent mental and physical dependency upon others for their welfare.

Case in point: "...which I might add the government is providing for you at considerable tax payer expense".

(Report Comment)
Michael Williams March 4, 2014 | 9:57 a.m.

Chris: You say, "Just to clarify, the governemnt is subsidizing your health care. If you turned 65 in 2010, lifetime medicare taxes for the average couple were $61,000 and lifetime medicare benefits were $180,000, which is roughly a $100,000+ subsidy."

I agree. The gov't IS subsidizing my health care.

And you think I agree with that approach? Your statement begins with the premise that I DO agree with the approach.

But, I don't.

I'd have been much better off keeping that money and investing it wisely. Same thing social security. It is not pleasant when I find out I've played the ant to your grasshopper. My response is "Go pound sand" to any able-bodied baby boomer now in a panic over health care and retirement.

My response to younger folks supporting all this boomer expense is....I'm sorry, but quit listening to folks who want to "give" you stuff. There's a price they are not telling you about.

The Missourian has done, and is doing, a crappy ACA reporting job.

(Report Comment)
Christopher Foote March 4, 2014 | 11:16 a.m.

What accounts for the disparity in enrollments by state? and is the answer not newsworthy? Note that enrollment represents the working poor having access to non-emergency room health care.

(Report Comment)
Michael Williams March 4, 2014 | 11:28 a.m.

Chris: Of COURSE it's newsworthy.

It's just that, to the Missourian, some things are more newsworthy than others.

Especially if it fits an agenda.

Given the body of evidence accumulated over my 43 year residency hereabouts, it's my only possible conclusion. The Missourian seldom publishes thoughts and articles not fitting a preconceived progressive agenda. Since they are somewhat tax-supported, I resent that. And so should you.

PS: The disparity in state enrollments DEFINITELY reflects the politics of the governing party of the state. Which, of course, reflects the wishes of the VOTERS in the state. What's not to like?

(Report Comment)
Ellis Smith March 4, 2014 | 12:37 p.m.

The Missourian's policies biased? Surely, Williams, you are grieviously mistaken! The Misourian hasn't got a biased bone in its collective body.

My total residence in Missouri, only about half of it in Columbia, was 47 years; excluding the time I spent as a student in MS&T, which is technically not mid-Missouri. I don't beleive that during that time I EVER saw the Missourian show the slightest bias.

A week from this Saturday we will celebrate the 106th CONSECUTIVE ANNUAL St. Patrick's parade at 11 AM in Rolla at MS&T. No other institution of higher learning in the United States or Canada does this; it qualifies as an long tration, not just at MS&T but also for University of Missouri System.

Would it devestate the Missourian to send a photographer 95 miles south of Columbia to snap a few photos? We'll be there, no matter if there's recipitation* and no matter what the temperature*, even though for some of us it's not a short trip to get there.

Our students voluntarily give up part of their Spring Break for St. Pat's weeek celebration; they don't receive any more days for Spring Break than MU, UMKC or UMSL students do.

We DARE you to show up with your camera!

*-Over the years we've developed ways of "insulating" ourselves against cold and wet. :)

(Report Comment)
Michael Williams March 4, 2014 | 12:40 p.m.

Chris: Here's what I did with your data in the chart.

I tried to extrapolate to the x-axis and divide the reds and blues into two categories. I left out the "shaded" states because your graph does not say why those states were "shaded" and I was unsure which category to put them in.

I also left out the last 5 blue states, for reasons I'll explain below.

If you try to reproduce my values, you'll get close but not exact because your x-axis extrapolations will be different from mine. Your statistical conclusions will be the same, however.

I ended up with 21 red states and 15 blue states. I did a t-test analysis of the two unequal-sized samplings.

As expected from a visual analysis, the t-test showed a VERY high probability (<<0.001) the means were not from the same populations.

Good so far.

Except, let's look at the means. For red states, the mean enrollment for the eligible population was 5.9%. For blue states, the mean enrollment was 7.6%.



This is an example of statistical differences having no practical value, and certainly no explanatory value, at all!

The ONLY way you can show any statistical differences with practical value is if you include 5 other blue states...states that are already outliers from the rest (yes, I did that test, too). If we DO include those states, the magnitude of the mean difference DOES get larger. The mean for red states (N = 21) is 5.9% while the mean for blue states (N = 20) is ca. 11%.

So, what we have here is a doubling, from 5.9% to 11% that this article is trying to ascribe to onerous state regulations.

SO, my question to YOU is to what do you ascribe the remaining 90-95% NON-ENROLLMENT??????

(Report Comment)
Michael Williams March 4, 2014 | 12:41 p.m.

Ellis: "Would it devestate the Missourian to send a photographer 95 miles south of Columbia to snap a few photos?"

Too far to bicycle, so yer outa luck.

(Report Comment)
Ellis Smith March 4, 2014 | 12:49 p.m.

Prior comment, above.

Sorry, I hit the wrong key and posted that before making some corrections:

3rd paragraph, "tradition"
4th paragraph, "devastate," "precipitation"

(Report Comment)
Michael Williams March 4, 2014 | 1:08 p.m.

Chris: "SO, my question to YOU is to what do you ascribe the remaining 90-95% NON-ENROLLMENT??????"

Or, to put it another way, only TWO states have enrollment great than 15% of eligible citizens: Washington and Vermont. EVEN IF I AGREED with your graph and conclusion that regulatory activity accounts for the differences, YOU have to address why in the hell 85-95% of the eligible population has NOT enrolled!

You're talking about 5 to 15%. INO, you are ignoring the remaining 85-95% of the problem. That's similar to the old adage of spending 95% of your time trying to solve 5% of the problem.

The problem you have with your graph is two state outliers and a really bad scale on the X-axis. My argument would be a LOT different if the x-axis scale ranged up to 80-90% and was filled by blue, but not red. Hell, under such circumstances, I might have even agreed with you.

This article is trying to extrapolate very poor enrollment data from red AND blue states to the entire eligible population using onerous regulations as the horrible, political cause. That's cow pie.......

(Report Comment)

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