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Columbia Missourian

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

By Frances Webber
March 3, 2014 | 7:34 p.m. CST

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.


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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:

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:

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.