Virginia Young, St. Louis Post-Dispatch, Author at �鶹Ů�� Health News

Missouri’s Declining Medicaid Caseload Stands Out In National Report

Virginia Young, St. Louis Post-Dispatch — Mon, 02 Jun 2014 11:54:44 +0000

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Missouri is seeing a bigger decline in its Medicaid rolls than nearly any other state, a ranking that the administration of Gov. Jay Nixon attributes to an improving economy and critics blame on application snafus.

compares Medicaid enrollment in March to the average for the three-month period of July through September 2013. Missouri’s caseload declined 3.9 percent, a drop second only to Wyoming, which declined by 5.6 percent.

The Missouri Department of Social Services, which oversees Medicaid, attributed the decline to more people finding jobs.

“As the economy has improved, fewer Missourians are relying on assistance programs for support,” an agency spokeswoman said in an emailed statement.

The department has resolved a backlog that was delaying eligibility determinations, the spokeswoman said.

“The number of applications pending has returned to a normal volume, which is typically around 20,000,” the statement said.

Critics contend the state is making it harder for people to enroll or renew their coverage.

Nixon reorganized the department’s Family Support Division last year. The number of caseworkers at walk-in centers has been reduced and a new software system is being phased in for applications, which now are handled at remote processing centers.

Joel Ferber, an attorney at Legal Services of Eastern Missouri, ticked off these reasons for the enrollment decline:

“It’s the reorganization, it’s the staffing issues, it’s the new computer systems, it’s the slow pace, it’s the delays of getting through the backlog,” he said.

Rep. Jeanne Kirkton, D-Webster Groves, agreed. She said she heard frequent complaints from constituents.

“There are still some pretty major problems with people getting access in a timely manner,” she said. “They can’t talk to anybody” who can answer their questions and lost paperwork results in benefits being denied, she said.

Missouri is among 24 states that rejected an expansion of Medicaid that would have raised the income threshold to cover the working poor — adults making up to 138 percent of the poverty level, or $16,104 for an individual.

Nixon, a Democrat, supported the expansion. But the Republican-led Legislature opposed it, calling it unaffordable for both the federal and state governments.

Even so, most states that did not expand Medicaid saw increases in their enrollment — 2.6 percent, on average. That uptick is generally attributed to “the woodwork effect,” meaning people who were already eligible for Medicaid came out of the woodwork when publicity ramped up about the new health insurance mandate.

But that did not hold true in Missouri and six other states. Besides Wyoming, the other states that saw caseload declines were Alaska, Alabama, Louisiana, Nebraska and Wisconsin.

There were 829,585 Missourians on Medicaid in March, compared with the three-month average of 863,417 in July through September of 2013.

The data were compiled by the federal Centers for Medicare and Medicaid Services, which oversees the health care program.

According to the CMS report, more than 4.8 million people were added to the Medicaid and State Children’s Health Insurance Program rolls nationally during the period studied, an increase of 8.2 percent. The increase was 12.9 percent in states that expanded Medicaid.

March caseloads were compared with July through September 2013 because that period preceded the launch of the federally run marketplace where people can buy private insurance.

Low-income people who use the marketplace but are eligible for Medicaid are supposed to have their applications automatically routed to their states’ Medicaid programs in a seamless process.

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Missouri Medicaid Bill Wins Symbolic Committee Vote

Virginia Young, St. Louis Post-Dispatch — Wed, 30 Apr 2014 16:01:35 +0000

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JEFFERSON CITY, Mo. — In what Missouri House Insurance Committee Chairman Chris Molendorp acknowledged was a symbolic move, a Medicaid expansion measure gained its first committee endorsement of the year today.

Molendorp, R-Belton, and the four Democrats on his committee combined to recommend a wide-ranging bill that would expand the public health insurance system to about 300,000 low-income adults. The vote was 5-2, with five Republicans absent.

“If it makes people mad, what are they going to do, not vote for me?” said Molendorp, who is not seeking re-election. “I’m just going to stick it on any bill I’ve got left” in the insurance committee.

The 121-page proposal adopted by the committee is modeled on a plan developed by Sen. Ryan Silvey, R-Kansas City. It attempts to address GOP opposition to Medicaid expansion by requiring a host of changes, such as photo IDs for food stamp recipients and more transparent billing practices for hospitals.

But with only 11 days left in the legislative session and GOP leaders opposed to the bill, it’s unlikely to go any further. Molendorp acknowledged as much after the committee vote.

“You know, I’ve got these bills in my possession. I thought it makes sense to make a statement that the Republican Party needs to do the right thing, and this is all I can do as part of a voice in the wilderness in my party.

“So it’s symbolic and I understand that, but someone’s got to lead on this issue. I know it’s not going to go anywhere,” Molendorp said.

Then he was interrupted by Medicaid supporters who urged him to be more optimistic.

“This is an incredible proposal that I’m sure will be adopted swiftly by House leadership. How’s that?” he quipped.

The bill would set aside savings the state expects to gain by shifting some people who are currently on state-funded health care or traditional Medicaid into the expanded Medicaid coverage group.

The expansion group includes working-age adults earning up to 138 percent of the federal poverty level, or roughly $27,310 for a family of three.

While Missouri receives about 60 percent funding from the federal government for traditional Medicaid patients, those covered under the expansion would be paid 100 percent by the federal government initially, dropping to a 90 percent federal share by 2020.

Silvey estimates the state’s savings could add up to $600 million by 2019. He said the state’s tab for the newly eligible recipients could be roughly $200 million a year when it hits the 10 percent level.

If there wasn’t enough money in the “lockbox” account to pay the bills for the new Medicaid participants, Silvey’s plan would cover the balance by reducing the rates paid to medical providers, such as hospitals. He includes a five-year sunset clause, which means coverage would lapse for the newly covered adults unless the Legislature chose to renew it.

During the meeting Democrats expressed enthusiastic support for the bill, including a provision that would expand coverage to pregnant women making up to three times the poverty level.

“It’s a pro-life vote,” Molendorp exclaimed. “We’ve got some dental stuff in here. I think I got rid of term limits, too,” he joked. “There’s a lot of good stuff in here. Trust me.”

Rep. Jill Schupp, D-Creve Coeur, praised Molendorp.

“I think it’s great that he’s doing it,” she said. “I wish it was more likely to move forward.”

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Adding Dental Care Contrasts With Mo. Legislature’s Opposition To Medicaid Expansion

Virginia Young, St. Louis Post-Dispatch — Wed, 16 Apr 2014 15:18:46 +0000

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JEFFERSON CITY — Republican opposition in the state Senate has dimmed hopes that Missouri will expand Medicaid this year to cover the working poor

But agreements are percolating on what might be called Medicaid Expansion Lite.

In the most far-reaching move, next year’s state operating budget almost certainly will restore limited dental coverage for 300,000 low-income adults whose benefits were cut in 2005. Coverage for rehabilitative therapy also might be reinstated.

There’s a chance lawmakers will let elderly and disabled people stockpile small nest eggs without losing their Medicaid coverage, a change that could add 8,174 adults to the rolls.

And liberals and conservatives alike back a bill covering more pregnant women by including “unborn children” in the state Children’s Health Insurance Program, an arm of Medicaid. An estimated 1,844 women could gain prenatal services.

Legislators pushing the piecemeal additions include Sen. Rob Schaaf, a physician and one of the staunchest opponents to the federal Affordable Care Act’s blanket Medicaid expansion. He portrays the changes as reforms that would save taxpayers money by decreasing emergency room use.

Dental care “is part of the safety net that we just completely ignored for people who are dependent on us,” Schaaf, R-St. Joseph, said last week. “This is as preventative as it gets.”

Supporters of full-blown Medicaid expansion say piecemeal changes are helpful but won’t generate the $2 billion a year in federal funds and 25,000 jobs that Missouri could gain if eligibility were broadened as envisioned by federal law.

The broader plan would cover about 300,000 Missourians making up to 138 percent of the poverty level, or $16,104 a year for an individual. The federal government would pay the full cost for two years, with the state’s share phasing up to 10 percent by 2020.

On Tuesday, Gov. Jay Nixon, a Democrat, announced a state website, , that aims to track the federal money Missouri has given up by rejecting the larger expansion. He pegs the loss at $5.47 million a day.

Nixon said in a statement Tuesday that broad expansion was more cost-effective because the state would “cover zero percent of the cost now. The General Assembly’s approach to expanding Medicaid covers fewer people, and makes the state pick up 36 percent of the cost.”

Incremental changes “are all good,” said Rep. Chris Kelly, D-Columbia, “but they all pale before expansion.”

TOOTHACHES IN THE ER

Medicaid provides free or low-cost health insurance for 828,478 low-income Missourians. About 60 percent are children. The rest are custodial parents, pregnant women, the elderly and people with disabilities.

There are varying eligibility thresholds. For example, Missouri’s income cutoff for parents — 19 percent of the poverty level — is the lowest allowed by federal law. But children are covered in families earning up to 300 percent of poverty, which is among the highest levels nationally.

In 2005, then-Gov. Matt Blunt and the Legislature eliminated an array of services, including dental care for most adults. Republicans said the cuts were needed to balance the budget and free up money for other priorities.

Since then, Medicaid has provided dental benefits only for children and for adults who are pregnant, blind or in nursing homes. That leaves out Ebonnee Estes, 28, of St. Louis. She said she had been unable to find a dentist she can afford, especially since she was laid off as a nurse’s aide in February.

“I have two teeth that are chipped, and one has developed a cavity,” she said. “I do not have dental coverage, so it’s too much money to be able to come up with.”

Because poor oral health care can lead to teeth decay and infection, people without dental insurance often wind up in emergency rooms, where services are more costly. Then the underlying problem, such as an abscessed tooth, may go untreated.

“Sometimes the emergency room will just give out a painkiller,” said Tom Farmer, a dentist from Clayton who sees Medicaid and uninsured patients at his walk-in clinic in north St. Louis.

“They won’t give out any antibiotics. Or the person will go to the emergency room multiple times. Finally they show up and the emergency room can’t help them or the infection’s so bad, they end up in the hospital.”

Those arguments persuaded the House to earmark $48.2 million in federal and state funds to restore adult dental care in the budget that takes effect July 1.

The Senate has not yet voted on the budget, but dental coverage is virtually certain to pass because last week, the Senate Appropriations Committee approved the same amount as the House did.

However, the Senate committee carved it up differently. Instead of a full package of dental benefits, the Senate would fund only 30 basic procedures, such as exams, X-rays and extractions.

By leaving out high-tech treatments, such as bone biopsies, senators reserved $17 million to raise the rates Medicaid pays dentists. They would draw 60 percent of the usual rate, up from about one-third of the norm. The Missouri Dental Association proposed the rate increase to encourage more dentists to participate in Medicaid.

POTENTIAL ADDITIONS

Dental care isn’t the only service that was slashed in 2005 but will be back on the table when House and Senate negotiators reconcile their budget differences.

The House also wants to reinstate occupational, speech and physical therapies for adults.

A licensed physical therapist, Rep. Sue Allen, R-Town and Country, said it made no sense to cover the cast and surgery for a broken wrist, for example, but not the therapy to help the injured person regain strength and range of motion.

Other additions in the House-passed budget include individually fitted wheelchairs, an asthma education program, a pilot program to coordinate care for foster children and rate increases for Medicaid providers.

Meanwhile, the program’s rolls could grow slightly under several bills that would help the elderly, people with disabilities and pregnant women.

Currently, a single elderly or disabled person on Medicaid can accumulate savings of no more than $1,000. For a married couple, the maximum is $2,000.

Set in the 1960s, the asset limits make it hard for people to stay in their homes, because they can’t afford major repairs.

“We all know, when you have a home, things go wrong all the time,” Joanie Gillam, a supervisor at the Disabled Citizens Alliance for Independence in Viburnum, told a Senate interim committee on Medicaid transformation.

The committee proposed a wide-ranging overhaul that includes doubling the asset caps. Though it has bipartisan support, it has bogged down because of some senators’ fears that the bill could be amended to include the broader expansion of Medicaid eligibility.

“The key is to make sure they understand we’re putting together a program that’s a Missouri plan,” said the sponsor, Sen. Gary Romine, R-Farmington. “A lot of folks don’t like the federal government forcing a plan down our throats.”

If a Medicaid reform bill begins moving, adding “unborn children” is among the ideas that could gain traction.

Called the Show-Me Healthy Babies program, the proposal would give women making up to three times the poverty level coverage for pregnancy-related services and two months’ postpartum care.

“There’s a lot of people who want to see that across the finish line,” said the sponsor, Rep. Jeff Grisamore, R-Lee’s Summit. Currently, pregnant women are covered at 185 percent of poverty.

The outlook for the broader Medicaid expansion envisioned by the Affordable Care Act is much less promising. Some proponents say the broader expansion could pass in the House. However, opponents — who call the expansion financially unsustainable — have signaled they would use a filibuster to block it in the Senate. For that reason, many say it’s probably dead for this year.

“It has an extremely high hill to climb,” Senate President Pro Tem Tom Dempsey, R-St. Charles, told reporters Monday.

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Kit Bond Works Missouri Capitol’s Halls On Medicaid Expansion

Virginia Young, St. Louis Post-Dispatch — Mon, 07 Apr 2014 13:21:00 +0000

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Christopher “Kit” Bond is back.

The two-term governor (1973-76 and 1981-84) has been walking the Missouri Capitol’s hallways and meeting with legislators, some of whom weren’t born when he first came to Jefferson City as state auditor in 1970.

Bond’s Columbia, Mo.-based consulting firm, Kit Bond Strategies, was hired in January by the Missouri Chamber of Commerce & Industry to lobby for legislation that would expand Medicaid to about 300,000 low-income adults.

Bond didn’t just put his name on the campaign. He has taken an active role in shaping the plan and delivering the message.

“He’s no show pony,” said Brendan Cossette, a chamber lobbyist. “He’s engaged.”

Bond said in an interview recently that he has met with 15 to 20 state senators, including some of the Senate’s staunchest Obamacare opponents.

Though Bond strongly opposed Obamacare when he was a U.S. senator, he said it’s time for legislators to ask themselves: “Did you work to get a responsible solution? Or did you just dig in your heels and say, ‘Philosophically, I’m opposed to it.'”

He said he asks them to consider the price of inaction, including “how much money would come to Missouri that does not come here, how many health providers lose their jobs, how many needy people wind up in the emergency room to get primary care, which will drive up the cost of insurance that pays for the hospitals’ cost.”

Bond and his team worked with Sen. Ryan Silvey, R-Kansas City, to draw up a plan that attempts to address the critics’ main concerns, such as whether the state could afford the $200-million-a-year cost of the new Medicaid participants once Missouri had to pay 10 percent of the bill.

Basically, Silvey’s plan would pay for the newly eligible adults with savings the state expects to accrue from shifting some people to federally funded health care. If the federal government reduced the share it promised to pay, the state would cut off the coverage.

Other ideas in Silvey’s proposal are listed under headings such as “entitlement reform” and “taking ownership act.” They include greater use of private managed care plans, co-pays for inappropriate use of emergency rooms and photo IDs to reduce food stamp fraud.

“It’s a workable plan,” Bond said. “It protects the state budget and it provides the hardworking Missourians who are in the (coverage) gap with health care coverage and it allows us the chance to bring some sound principles” to managing Medicaid.

“It’s a Missouri solution,” he said. “This is the one opportunity to get some real reform in Medicaid. My good conservative friends and I have been talking about getting reform, because the system right now is not under control.”

Silvey was a logical choice to carry the ball: He is a former legislative aide to Bond.

The chamber’s president, Dan Mehan, also once worked for Bond, as did another key Medicaid lobbyist, Joe Pierle, executive director of the Missouri Primary Care Association.

Said Bond: “It’s sort of like a reunion, but I trust all those people, they trust me.”

Bond, 75, splits his time between his family’s homestead in Mexico, Mo., and a home in St. Louis. He said he has generally been meeting with senators one-on-one. No session is planned with the Senate Republican Caucus.

“They’ve been very kind to let me hang around the Senate, but I don’t envision them inviting me to the caucus,” Bond said.

Though there are only six weeks left in the legislative session and opponents have promised to filibuster the bill in the Senate, Bond optimistically called the issue a “toss-up.”

“At one point they were calling us Don Quixote, tilting at windmills, but the Don Quixote folks are making some strong points,” Bond said. “All we want is careful consideration by the members of the Senate on what happens to Missouri if this doesn’t pass, and what happens if it does.”

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New Attack On Obamacare Filed In Missouri Legislature

Virginia Young, St. Louis Post-Dispatch — Tue, 14 Jan 2014 19:09:46 +0000

Missouri would strike another blow against the federal Affordable Care Act under a bill filed by state .

The bill would suspend insurance companies’ state licenses if they accepted subsidies offered by the federal government to help pay health insurance premiums for low- and middle-income Missourians.

Lamping contends the subsidies are illegal and eventually will be thrown out by a federal court. By rejecting them, he said, Missouri could remove the trigger in the federal law that, beginning in 2015, will assess penalties against large employers that don’t provide health insurance.

“This is a legislative way by which the state actually could push back” against the law, Lamping said.

Critics of Lamping’s plan say that the Affordable Care Act is helping people obtain health insurance and that it’s time to stop fighting it. An estimated 47,000 Missourians were found eligible for subsidies as of Dec. 28, according to federal data released Monday. The law provides subsidies for people earning up to 400 percent of the poverty level, or $78,120 for a family of three.

The bill would “just throw a wrench in the whole situation, slow everything down,” said .

The insurance industry is watching the bill closely.

“We’re kinda caught in the middle,” said Brent Butler, government affairs director for the . “We’ve spent three years since the adoption of the Affordable Care Act informing everybody of the changes that will happen in the marketplace. This might add more questions than answers.”

It wouldn’t be the first time Missouri had tried to halt the federal health care law, dubbed Obamacare.

In 2010, about 71 percent of Missourians voted to oppose the mandate to purchase insurance and in 2012, nearly 62 percent voted to prevent the governor from setting up a state-based insurance exchange. As a result, Missouri is one of 36 states where the federal government is operating the exchange, an online marketplace that allows consumers to compare health plans and sign up for coverage.

In Missouri, two companies are participating in the exchange: Anthem Blue Cross Blue Shield, which is operated by Wellpoint, and Coventry Health Care Inc., which was acquired by Aetna last year.

Lamping said he got the idea for his bill suspending the insurers’ licenses from . Cannon traveled the country, encouraging states not to set up insurance exchanges. He argued that employers would have a solid legal foundation to contest any penalties in states with federally run exchanges.

The strategy is based on a contention that the Affordable Care Act allows the federal government to give out health insurance premium subsidies only if the insurance exchange is run by the state.

Several lawsuits advance that argument, including Halbig vs. Sebelius, which is pending in federal district court in the District of Columbia. It cites a section of the law that says subsidies apply to policies purchased “through an exchange established by the state.”

The act’s defenders say Congress intended the subsidies to apply to all qualified people and the lawsuits take provisions out of context. Any drafting errors can be fixed by regulation, the law’s supporters say.

Lamping said Missourians have made their distaste for the law clear, and he is trying to put teeth into Missouri’s resistance to its provisions.

“Clearly, in Missouri, there’s a very strong sense that they don’t want this law,” he said.

This story is part of a collaboration that includes and Kaiser Health News.

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Missouri Governor Pushes GOP-Led Legislature On Medicaid Expansion

Virginia Young, St. Louis Post-Dispatch — Thu, 02 Jan 2014 21:06:56 +0000

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Missouri Gov. Jay Nixon, a Democrat, is intensifying his effort to persuade Republican lawmakers to expand Medicaid with a pitch that uses some of the same themes that Republicans favor.

At a news conference in his Capitol office this week, Nixon praised states such as Iowa and Arkansas for designing “common-sense, market-based approaches” that encourage personal responsibility on the part of Medicaid participants.

Those states “have seized this opportunity to implement innovative reforms, like rewards for making healthier lifestyle choices and penalties for missing doctors’ appointments or showing up at the emergency room with a stuffy nose,” Nixon said.

The governor and a coalition of business, labor and health care groups pushed during the last legislative session to expand Medicaid to the working poor, but the bill was shelved by the Republican-led Legislature. Critics said Medicaid is a broken, inefficient system and the federal government can’t be trusted to keep its promise to fund the expanded program.

Nixon said the dynamics will be different this year because the federal government will, in fact, be financing the expansion in states that accepted it. A recent study estimated that Missouri will turn away $2.2 billion in federal funds annually.

“As of 12:01 tonight … Missouri’s tax dollars are going to be used in New Jersey, Iowa, Arkansas and other parts of the country to solve their problems, and that’s not the way we like to do things in our state,” Nixon said.

Under the Affordable Care Act, the federal government will pay most of the cost to insure working-age people who make up to 138 percent of the federal poverty level, or $32,500 for a family of four.

Federal money will cover the tab for newly eligible participants the first three years, with states phasing in up to a 10 percent share of the cost after that.

Currently, Medicaid covers more than 875,000 Missourians — low-income seniors, people with disabilities and some families with children. Opponents say that even without expanding eligibility, the program’s cost to the state rises by $71 million a year.

“Missouri’s Medicaid system is already expanding at an unsustainable rate,” House Social Services Appropriations Chairwoman Sue Allen, R-Town and Country, wrote in a recent newsletter.

Whether Nixon and opponents can find any middle ground appears to be a long shot.

Rep. Jay Barnes, R-Jefferson City, drew up a proposal that would place people below the poverty level in the traditional Medicaid program and cover those making up to 138 percent of poverty by paying their premiums for private insurance.

But the House Interim Committee on Medicaid Transformation, which Barnes chairs, was cool to the idea and has not issued any recommendations.

So far, Nixon and legislators haven’t even been able to agree on a format for a joint brainstorming session.

Nixon invited House and Senate committees studying Medicaid to a round-table summit in November. But he canceled it after legislators decided to treat the meeting as a legislative hearing, where Nixon would testify and answer their questions.

“Governors don’t do that,” Nixon said testily in answer to a reporter’s question about why the summit fell through. “We wanted to have, and I still look forward to having, a thoughtful discussion. This is not a gotcha moment for either side.”

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As Missouri Marketplace Opens, Focus Is On Recruiting Young Adults

Virginia Young, St. Louis Post-Dispatch — Tue, 01 Oct 2013 11:50:00 +0000

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MEXICO, Mo. — Sher-rÈ Bird, 30, doesn’t see much point in buying health insurance.

“Why pay for insurance you’re not going to use?” said Bird, who waits tables at a popular diner on the courthouse square here, about 120 miles west of St. Louis. “I don’t go to the doctor that often.”

Her attitude foretells the challenge faced by the national campaign that kicks off today to get the uninsured to use new online marketplaces to buy health plans.

The interactive websites are set to launch at 7 a.m. today, even if the federal government is partially shut down due to the ongoing fight in Washington over the health care law.

Sick and older people who lack affordable health care options are likely to flock to the insurance plans, which for the first time cannot exclude people based on pre-existing health conditions.

But for the marketplaces to succeed, plenty of healthy, young adults must participate. A pool made up primarily of people with medical problems would drive up the premiums.

So Bird and other 18- to 34-year-olds are likely to be bombarded with pleas to check out the options.

Through enrollment events, social media, targeted ads and mobile apps, the message will go out to young adults that: a) you may owe a penalty if you don’t buy insurance; b) you may be eligible for federal tax credits to pay for a health plan; and c) you’re not invincible.

The big unknown — for young adults and other consumers alike — has been how much the policies will cost. That question will finally be answered today when the plans are unveiled on the healthcare.gov website in the 27 states with federally managed insurance exchanges.

Julie Brookhart, a spokeswoman for the Centers for Medicare and Medicaid Services, said the exchanges will open “with full functionality … and consumers will finally be able to shop and enroll in quality, affordable health coverage….We have worked to ensure consumers will have a wide range of ways to sign up for health coverage this fall, including online, over the phone or in person.”

Beginning next year, most people will be required to carry health insurance or pay a penalty. The fine is $95 in the first year, or 1 percent of taxable income, whichever is greater. The penalties will rise in subsequent years.

While word about the penalties seems to be getting out, polls have shown that many consumers don’t know about the exchange. Three-fourths of the uninsured who were surveyed last month by the Kaiser Family Foundation were unaware the marketplace was about to open.

Count Bird, of Mexico, in that group. “I’m gonna get fined if I don’t” buy insurance, she said last week as she rested after the lunch crowd eased at the Jackson Street Diner. “To me, that’s pretty crappy.”

In addition to working three days a week at the restaurant, she puts in two days a week at an agency that helps businesses line up temporary employees. Neither of her jobs offers health insurance.

She had a medical visit scheduled the day she was interviewed, to see about a severe abscess on her finger. But Bird said a charity care program would help cover that.

She said she doesn’t have room in her family budget for insurance that would likely run more than $300 a month, compared to $40 a year if she only has to pay for one doctor’s visit.

“Whenever you’re on a budget, your budget gets tighter when you have to buy something you’re not going to use,” Bird said.

Advocates for the health exchange will try to respond to precisely that sentiment. For a peek at the message, take a look at a video by Jason Girouard, of Brimfield, Mass., who won $1,500 in the for an entry titled: “We are not invincible, we are human.”

In Girouard’s video, the hero appears in a red mask and cape to proclaim himself “king of the world.”

Then he tumbles and breaks his arm, an injury that would cost him $8,000 without insurance and which provides an example of the high rate of emergency-related visits experienced by young people, according to the video.

The contest — which is taking online votes now for additional prizewinners — was overseen by a Washington-based group called . The name is a tongue-in-cheek takeoff on the popular assertion that the young spurn insurance because they don’t think they need it.

“That’s the myth, that all young people think they’re healthy and don’t need health insurance,” said Brian Burrell, regional manager for Young Invincibles.

In fact, cost is a bigger reason that about a fourth of 18- to 34-year-olds in Missouri are uninsured, he said.

Young Invincibles, which was founded by Georgetown law students in 2009, received $100,000 from the Missouri Foundation for Health to handle “outreach” to young Missourians.

The pitch, which will hone in on students at community colleges, is that most young people enrolling in plans through the exchange are likely to be eligible for tax credits that will lower their monthly premiums. The tax credits will go to single people earning up to $46,000 or a family of four making up to $94,000.

Young adults, who have lower median incomes, “will be receiving tax credits at a higher rate than the general population,” Burrell said.

One study found the price for a 21-year-old buying a mid-range policy averaged about $270 a month, before government subsidies kicked in. That study, by Avalere Health, looked at 11 states and Washington.

For adults under age 30 and on a budget, another option is a catastrophic plan, though it has disadvantages. These plans require high deductibles of more than $6,000. Also, federal subsidies cannot be used to help pay premiums under that option.

“It’s better than having no health insurance. But we want to make sure people are getting educated that there are a lot of out-of-pocket costs” with a catastrophic plan, Burrell said.

For the uninsured, unexpected accidents can take a financial toll. Burrell said he broke his pinkie playing in a recreational softball league, an injury that would have cost $7,500 to $10,000 if he hadn’t had insurance.

The Affordable Care Act has already resulted in more insured young adults, because it allows them to stay on their parents’ insurance plans until they turn 26. The federal government says 55,000 young adults in Missouri have gained coverage this way.

The law’s critics, led by Lt. Gov. Peter Kinder, are urging consumers to use caution in buying policies on the exchange.

Kinder, who calls the Affordable Care Act “deeply flawed,” made headlines last week for encouraging people not to sign up. But his spokesman, Jay Eastlick, said Monday that Kinder is “not encouraging any kind of boycott of the health care exchange. He advises people to just know what they’re signing up for.”

So far, federal officials have provided only sketchy details about the participation of insurance companies and their particular product offerings.

According to the Department of Health and Human Services, at least two insurers will be offering products in the exchange in Missouri. Each of the state’s 10 insurance rating districts, including the St. Louis area, has two insurers participating, federal officials say.

In the St. Louis area, Anthem Blue Cross Blue Shield in Missouri and Coventry Health Care Inc., which is based in Bethesda, Md., plan to participate.

In the Kansas City area, Coventry again will be participating, along with Blue Cross Blue Shield of Kansas City. Information about the state’s other rating areas has not yet been released.

Insurance counselors, called “navigators,” are supposed to be available at various health care centers and social service organizations to guide consumers through the application process. But the training and licensing process has hit a few bumps.

So far, the state has licensed about 80 counselors, and about half of those licenses were issued Monday. As of late Monday, the navigators had not yet been told which policies would be available on the exchange.

The initial enrollment period will run through the end of March, though people who want coverage effective Jan. 1 must sign up by Dec. 15.

Jeremy Milarsky, one of the first licensed Missouri navigators, said he will be ready. Milarsky manages navigators at Primaris Healthcare Business Solutions, which received $1 million in federal funds for counseling by 11 organizations around the state.

He said he had two appointments scheduled with consumers in Columbia, Mo., on Tuesday.

Jim Doyle of the Post-Dispatch contributed to this report.

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Missouri, Illinois Health Insurance Exchanges Gear Up Quietly

Virginia Young, St. Louis Post-Dispatch — Mon, 23 Sep 2013 14:14:00 +0000

This story was produced in partnership with the

Jefferson City, Mo. — Across the country, states are featuring celebrities, quirky songs and football game-day ads to promote the Oct. 1 debut of the online health insurance exchanges.

Minnesota’s multimillion-dollar campaign, for example, stars Paul Bunyan and Babe the Blue Ox in zany situations in which the lumberjack unexpectedly needs medical attention — and health insurance.

It’s been much quieter in Missouri.

A coalition of health care providers, community groups and faith-based organizations will try to get the word out this fall to the more than 800,000 uninsured Missourians.

Their message: “Using the Missouri Health Insurance Marketplace is Easy!” declares a glossy handout prepared for the Cover Missouri coalition.

The decidedly low-profile campaign here stems from state voters’ overwhelming passage last year of a law barring the governor from setting up an insurance exchange without legislative or voter approval. As a result of that vote, Democratic Gov. Jay Nixon has adopted a hands-off stance on the divisive issue and the federal government will operate Missouri’s online marketplace.

Despite the lack of catchy slogans, people are starting to pay attention, said Stephene Moore, regional director for the U.S. Department of Health and Human Services office in Kansas City. She and her staff have been talking to groups about the federal Affordable Care Act since Congress passed the landmark law three years ago.

“A lot of the time I joke with people, ‘How many of you waited to do your taxes or your Christmas shopping?’ People tend to wait” until the last minute, she said.

Officials are stressing that the enrollment period runs through March and that there’s plenty of time to figure out the various health plans, which have yet to be unveiled in Missouri or Illinois.

“It’s not a sprint on Oct. 1,” said Mike Claffey, who works in the Illinois governor’s office and is the state’s spokesman on the health care issue. “It’s a longer race to the finish line.”

Beginning next year, most people will owe a penalty if they don’t have insurance through a job-sponsored plan, another private plan or a public plan such as Medicaid or Medicare.

That’s the crux of the individual mandate, the keystone of the Affordable Care Act. The mandate aims to create a broad pool of insured people — especially healthy people ages 18 to 34 who need less care.

That group is dubbed the “young invincibles” because they tend to think they won’t get sick. In Missouri and Illinois, an estimated 25 percent of young adults are uninsured.

“Obviously, with this new system, you want a lot of people in the system, to help subsidize the cost impact with everybody carrying insurance,” said David Smith, a lobbyist for Anthem Blue Cross Blue Shield of Missouri, which plans to sell insurance in the Missouri exchange.

“At the end of the day, you’ve got the healthy population that’s going to subsidize the unhealthy population,” Smith said.

Once the exchange opens, Missourians who are uninsured or lack affordable coverage at work can go to the website, , to compare health plans and buy one, often with a federal subsidy.

The process is slightly different in Illinois, which is partnering with the federal government to set up an exchange. Illinois will have its own “landing page,” where people can start the application process. That website has not yet been announced but can be found on Oct. 1 by going to the main state page, .

The landing page will ask Illinois consumers to type in basic data such as income and family size. Based on that information, they will be directed either to a site to apply for Medicaid, the public program for the poor, or to the federally run marketplace to buy private insurance.

Illinois expanded Medicaid to cover an additional 200,000 people next year, as the federal law envisioned.

Missouri’s Republican-controlled Legislature rejected the Medicaid expansion, leaving an estimated 226,525 people below the poverty line in a coverage gap, without subsidized insurance. Legislators may re-examine the eligibility issue next year as part of a bill revamping the program to make it more cost-efficient.

In the meantime, health care advocates are encouraging uninsured consumers to set up accounts on the healthcare.gov website and learn the basics about shopping for insurance. There are application checklists, insurance cost calculators, live chats and links galore on the site.

What Will It Cost?

What’s still missing is the most important detail: price.

Neither the Illinois, nor the Missouri exchange has released how much the plans will cost. Officials will say only that the premiums and other details will be posted on or by Oct. 1.

How much one-on-one assistance will be available to help consumers sort out the options depends on the type of exchange a state is using. The bottom line: Missouri is getting much less federal money for such efforts than Illinois.

The Affordable Care Act earmarked a large pool of money for states that set up their own exchanges or partnered with the federal government on outreach.

Sixteen states and the District of Columbia are building their own exchanges. Seven states — including Illinois — are partnering with the federal government.

Illinois received $115 million for outreach and marketing. About $33 million of the money went to St. Louis-based FleishmanHillard to design an advertising campaign, which has not been unveiled.

More than $36 million went to community groups in Illinois that will help people enroll.

By contrast, Missouri — one of 27 states that ceded control of its exchange to the federal government — received $4.74 million for outreach. Most of that money went to community health centers to hire 59 insurance counselors.

To bolster those efforts, the Missouri Foundation for Health, a St. Louis-based nonprofit agency, provided $5 million in grants to community organizations that will hire counselors. Once the exchange is running, you can find the locations of the counselors listed at .

Even so, the foundation says counselors will be hard-pressed to handle the workload.

“We’re going to need volunteers in Missouri,” said Ryan Barker, the foundation’s vice president for health policy.

The foundation is spending $1.8 million on marketing, and $1.7 million of that went to FleishmanHillard to shape a public relations campaign. It will rev up after the enrollment period begins.

In addition to the FleishmanHillard campaign, Missourians also will see some targeted radio and digital ads for the exchange this fall under a contract that the Centers for Medicare and Medicaid Services signed with the public relations firm Weber Shandwick.

“It certainly is hard when there are still outstanding questions” about what the plans will cost, said Cynthia McCafferty of FleishmanHillard. “Right now, we can’t answer questions about what are the costs of the plans. Certainly there are challenges but there are always challenges, so you just work with it.”

The biggest challenge: Polls have found that most people remain wary of the 2010 health care law. A June Gallup poll found 52 percent of respondents surveyed nationally disapproved of it. On Friday, the U.S. House voted to defund the law.

Educating The Public

Against that backdrop, supporters say their best weapon is broader public understanding of the complex law.

The plans on the exchange will offer at least 10 essential benefits, including doctor visits, prescription drugs and hospitalization.

They will be grouped in four tiers — bronze, silver, gold and platinum — that vary based on cost. For example, with a bronze plan, a consumer will pay a lower monthly premium but a higher share of the costs when care is received.

Bronze plans will pay about 60 percent of the costs after premiums. At the other end of the scale, platinum will pay 90 percent of costs.

“Consumers are going to have a pretty wide array of choices to buy the coverage that fits their budget,” said Nanette Foster Reilly, a senior official in the regional office of the federal Centers for Medicare and Medicaid Services in Kansas City.

Most people who use the exchange are likely to be eligible for tax credits that will cover a considerable share of the cost for monthly premiums.

The credits will go to people who make between 100 percent and 400 percent of the federal poverty level — for example, between $23,550 and $94,200 for a family of four.

To see if they’re eligible for subsidies, consumers will plug in an estimate of their 2014 income, which will be cross-checked through a federal data hub linked to the IRS, Homeland Security and other agencies.

The verification will occur “in near-real time,” said Foster Reilly. If there are discrepancies that can’t be resolved, the consumer will get a list of items to check, she said.

Applicants also will automatically be screened for eligibility for Medicaid. If their income is below the state’s threshold, the exchange is supposed to electronically send the applicant’s information to the Medicaid portal.

Though Missouri didn’t expand Medicaid, many children are already eligible but not enrolled. When their parents use the exchange, the state has estimated that an additional 24,617 children will wind up on the Medicaid rolls.

The enrollment period for the exchange runs through March 31. Coverage will begin as soon as Jan. 1 for those who enroll by Dec. 15.

“There’s been a lot of emphasis on Oct. 1 as the launch date,” said Claffey, the spokesman for the Illinois exchange. “We are emphasizing that it’s really a 2½-month enrollment period if you’re looking for coverage on Jan. 1.”

The penalty for not having coverage starts out fairly low — $95 per adult and $47.50 per child, or 1 percent of family income, whichever is greater — with the fees growing in subsequent years.

Some people will be exempted from the penalty. For example, there’s no fine if your family income is below the threshold for filing a tax return — $10,000 per person or $20,000 for a couple — or if you would have been eligible for the expanded Medicaid program but you live in a state such as Missouri that did not adopt the expansion.

One section of the exchange will be geared to small businesses. The goal of the Small Business Health Options program, or SHOP exchange, is to give smaller employers the same kind of volume discounts that large employers enjoy, reducing the impact on rates that one worker with high medical costs can cause.

While officials say the exchange will be ready on time, the software was still being tested this month, so no one is certain how smoothly it will run until it launches.

“I’m waiting to see them flip the switch,” said Smith, the insurance lobbyist.

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Draft Report: Missourians Favor Medicaid Expansion

Virginia Young, St. Louis Post-Dispatch — Wed, 11 Sep 2013 10:21:07 +0000

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JEFFERSON CITY, MO. — They traveled to six, far-flung Missouri cities. They held marathon public hearings. They got detailed state briefings.

So what did the 52-member conclude?

That people want both Medicaid expansion and reform.

A seven-page draft report circulated by state Rep. Noel Torpey, R-Independence, the group’s chairman, ends with that statement. There is no elaboration. The rest of the report generally highlights testimony received, without naming witnesses.

For example: “Witnesses discussed the need for greater care coordination for Medicaid recipients and the benefits of giving recipients a stake in their health care.”

Though the report is light on details, Torpey said the undertaking could have a big impact on the Legislature’s Medicaid deliberations next year.

“I can look someone in the eye and say, ‘Representative, this is what we heard time and time again, and we need to keep an open mind’ ” about expansion, he said.

“I think if we do the right kinds of reform, there’s a chance of getting expansion done,” he said.

Last spring, the Republican-controlled Legislature rejected expanding Medicaid as envisioned by the Affordable Care Act. The federal government would have paid the full cost for new participants the first three years, with the state picking up a share after that.

Critics said that the safety net program for the poor was flawed and adding people to the rolls was financially unsustainable.

The topic is likely to be on the Legislature’s agenda again in January. The key question is, what reforms will legislators seek?

Asked for an example of a needed change, Torpey said Medicaid currently paid for knee replacements but not the follow-up rehab therapy. “That’s just crazy,” he said.

He also called for more transparency in hospital billing practices.

Some of the House working group members were disappointed that the group wasn’t given a chance to hash out specific recommendations. The panel included 14 legislators and 38 non-legislators, many of them with expertise in various health care sectors.

“You had this high-powered group of people that spent 90 hours of their own time and money, and (the chairman) never had them engage in a dialogue among themselves,” said Dr. Ed Weisbart, a member from Olivette.

He said some might have declined the appointment if they had known they were “just being a transcriptionist.”

Torpey said House Speaker Tim Jones, who appointed the committee, had been clear from the start that the group’s goal was simply to receive public testimony.

He said working group members could submit written comments, which will be appended to the report.

Then, the document will be handed off to , which will meet Wednesday morning to decide how to develop legislation.

A also will meet Wednesday morning. Experts from the Center for Health Law Studies at St. Louis University’s School of Law are expected to testify, among others.

The meetings will precede the Legislature’s annual veto session, which kicks off at noon.

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Missouri’s Poorest Residents Won’t Benefit From Obamacare

Virginia Young, St. Louis Post-Dispatch — Tue, 27 Aug 2013 08:26:58 +0000

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JEFFERSON CITY — 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 preventive 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, .

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.”

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