http://ozarkspub.vo.llnwd.net/o37/KSMU/audio/mp3/across-rural-missouri-large-coverage-gap-emerges-affordable-care-act_74067.mp3
Good afternoon, and welcome back to our Sense of Community Series on the Affordable Care Act, also known as Obamacare, and how it’s impacting people here in the Ozarks. This afternoon, we’re looking at how the new law uniquely affects people in rural or remote areas.
First, according to the official website, www.HealthCare.gov, the ACA funds scholarships and repays loans for doctors and nurses who work in rural areas with a shortage of health care professionals. ( That funding will come through the National Health Service Corps to the tune of $1.5 billion over five years.)
Traditionally, rural Americans have been less likely to get preventative care, like foot and eye testing for diabetics; the Affordable Care Act is heavy on prevention, and new insurance plans are required to cover prevention and wellness benefits.
Ryan Barker, a health policy analyst with the Missouri Foundation for Health, says one critical factor is that many rural jobs—like logging, truck driving, construction, and farming—often don’t come with health insurance.
“One of the really great things about the Affordable Care Act and these health insurance marketplaces is that it allows for a place for those small employers, or for individuals and families running that family farm, to purchase health insurance, and get the benefits of that large employer, group buying—and really get a more affordable price for health insurance,” Barker said.
Over at Ozark Action in West Plains, executive director Bryan Adcock oversees several programs that improve the quality of life for lower income Missourians. This office is the hub for five rural counties.
“A lot of the folks that we’re working with have to make decisions based on immediate need. You know, ‘Is food more important than medicine? Is medicine more important than shelter,’” Adcock said.
I set out to visit a rural health center for people without health insurance.
[Sound: automatic doors sliding open]
The sliding glass doors open at Missouri Ozarks Community Health in Ava, Missouri. The center receives federal funding, and charges patients on a sliding scale based on their incomes.
Debby Jeckstadt works as a Certified Application Counselor here answering questions about Obamacare, and signing people up through the exchanges, or marketplace on www.HealthCare.gov. She says about 200 people in Douglas County have sought her help with the Affordable Care Act.
“I actually had a couple [who] did not have health insurance at all – have never had it, even when they were working. They came in. They’ve done their homework. We actually did an application for them. They took the information home. Their premiums are going to run them about $60 a month, for the two of them, to get full coverage,” Jeckstadt said.
One of the main benefits of the federal health insurance marketplace, or exchange, is supposed to be the tax credits, or subsidies, that significantly offset the monthly premiums cost. And for people in a certain income level, that’s been really nice.
But in the process of doing her job, Jeckstadt learned that people who made 100% of the federal poverty level or less did not qualify for these tax credits – they fall into a new “black hole” of coverage.
“People are upset. They do look at it and say—they do fall in that gap—and they say, ‘But I thought this was for everybody,’” Jeckstadt said.
So, you might be asking: why in the world would Missouri’s poorest—those at or below the federal poverty level—be expected to pay full price on the new health insurance marketplace, or exchange, when people who make more than that get a discount through tax credits? Well, that’s because the Affordable Care Act was written with the expectation that those individuals would be covered by Medicaid – the government-run health care program for the poor.
But the US Supreme Court threw a serious curveball in 2012; it ruled that states didn’t have to expand Medicaid— it was optional if state lawmakers wanted to.
In Missouri, as it stands, non-custodial adults do not qualify for Medicaid, no matter how poor, unless they have a disability. The states that decide not to expand Medicaid are on the path to becoming the ones that see the rural poor hit hardest – and Missouri is one of them.
Rural hospitals are also bracing for serious hits: the Affordable Care Act included significant cuts to the reimbursements they get, which were supposed to be offset by all the new Medicaid-covered patients. The cuts to reimbursements are going ahead—they’re in the law—but the Medicaid patients don’t exist because Missouri has so far opted to not expand Medicaid.
Again, Ryan Barker with the Missouri Foundation for Health.
“The way the Affordable Care Act was constructed is: these new health insurance marketplaces, there are tax credits, or subsidies, to help people afford coverage. But the subsidies are available if your income as a family is between 100% or 400% percent of poverty—which, for an individual, is about $11,000 at the poverty level, up to about $45,000 for that 400% of poverty. The tricky thing is, because eligibility in Missouri’s Medicaid program is very low for parents and doesn’t exist for childless adults, is that if you are under the poverty level, there are no subsidies for you in the marketplace and you’re not Medicaid eligible. So, what it does is: it creates a gap, so that if you fall in those low-income categories, you don’t have Medicaid coverage and you’d have to pay full price in the marketplace—which nobody could afford to do,” Barker said.
When asked whether anything was being done about that coverage gap on the policy level, Barker said that is what the Medicaid expansion discussion addresses.
In a conference call two weeks ago, I asked US Senator Claire McCaskill, who voted for the Affordable Care Act, what the federal government was going to do about the coverage gap that Missouri’s poorest are falling into.
She emphatically answered that the federal government had already done something: it’s offering to pay the full tab for the expanded Medicaid program for three years, and after that, 90 percent. She said the ball is now in the court of state lawmakers.
Arkansas state lawmakers voted last year to opt into the Medicaid expansion program.
But so far, Missouri’s Republican-controlled legislature has said it wants to reform Medicaid before taking federal money to expand it. In the meantime, those Missourians making less than 100% of the federal poverty level will not benefit one bit from the Affordable Care Act. Their only consolation, perhaps, is that most of them won’t be expected to pay the fine for not having health insurance. That’s because they’re exempt due to their extremely low incomes.
For KSMU’s Sense of Community Series, I’m Jennifer Davidson.