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18,000 could lose health coverage in Missouri’s ‘bare counties,’ as state faces tough choices

Next year, Blue Cross Blue Shield of Kansas City will leave the individual health care marketplace in Missouri that was set up under the Affordable Care Act. And when it does, about 18,000 patients in 25 western Missouri counties will lose their health insurance. If those enrollees sign on to Healthcare.gov this fall to buy a replacement plan, they may have no options to choose from.

That's because those 25 counties could become "bare."

If that happens, Missouri will be the first state to have bare counties since the health care exchanges were established in 2013. Insurance companies leaving the marketplace, coupled with uncertainty over the health law’s future, have left thousands of Missourians who buy insurance on their own in a “wait and see” mode. Although other states have coaxed insurance companies to stay, Missouri’s regulators have not publicly shared their plans to rectify the situation.

“We will continue to work with insurers and other stakeholders here in Missouri and our legislators in Washington to do all we can to assist these impacted Missourians,” wrote Grady Martin, a spokesman for the state’s Department of Insurance, Financial Institutions & Professional Registration.

Though the Affordable Care Act made sweeping changes to all types of health insurance, critics frequently point to the struggles of the individual marketplace as evidence of the law’s failings. 

Tony Twitty, a St. Louis mechanic, purchased coverage for himself and his son on Healthcare.gov. He told St. Louis Public Radio last year that before the Affordable Care Act, buying coverage on his own was unaffordable.
Credit Durrie Bouscaren | St. Louis Public Radio
Tony Twitty, a St. Louis mechanic, purchased coverage for himself and his son on Healthcare.gov. He told St. Louis Public Radio last year that before the Affordable Care Act, buying coverage on his own was unaffordable.

Republicans argue that this is happening because the Democrats wrote a bad law, but Democrats say that Republicans are deliberately sabotaging it for political gain.  

Politics aside, here is what the debate means on the ground.

Who’s leaving the Missouri market? 

Missouri started the year in a particularly precarious situation because most of its counties only offer one option on the exchange. Though Centene announced it would enter the Missouri market in 2018, the company has not indicated where it will offer its plans.

Blue Cross Blue Shield of Kansas City, the sole insurer for 25 western Missouri counties, announced late last month that it would no longer offer plans on the Missouri exchange next year. Roughly 18,000 people in those counties who hold Blue Cross plans will lose their coverage at the end of 2017.


“Through 2016, we have lost more than $100 million. This is unsustainable for our company,” wrote Danette Wilson, the company’s president and CEO. “The uncertain direction of this market is a barrier to our continued participation.”

If no insurance company steps up to cover these counties, people hoping to buy individual insurance plans on Healthcare.gov would not have that option. They can purchase plans outside of the exchange with private brokers, but they would be unable to use federal subsidies to do so.

“If they’re older or low income, they might not be able to afford to buy their own coverage,” said Cynthia Cox, who researches insurer participation in states for the Kaiser Family Foundation. “It’s also possible that insurance companies could leave the off-exchange market, too.”

In Missouri’s case, rural counties were the first to run the risk of losing all options on Healthcare.gov. Potentially low enrollment in a given area can make it less attractive to insurers. Tiny Worth County, for example, is home to just 2,000 people near the Iowa border. In the last enrollment season, Blue Cross sold 118 plans there.

What's more, those areas have fewer doctors and hospitals to provide services. This puts insurers at an even greater disadvantage when they negotiate rates with doctors, who can demand higher pay because there is less competition nearby.

The issue could get worse if Anthem, the sole exchange insurer in 72 Missouri counties, serving 64,000 people, also chooses to leave. A spokesperson for Anthem said Monday the company would submit 2018 rates to regulators, but could still decide to leave the market later this summer.

“We are continuing an active dialogue with Missouri leaders and regulators in hopes that we can find a sustainable path moving forward, before we are required to make a decision on the exchanges,” wrote Deb Wiethop, spokesperson for Anthem in Missouri.

Anthem announced this month that it would scale back in Ohio’s individual market, leaving 18 counties there without an insurer.

Other states faced similar cliffs ... and then found options

Pinal County, Arizona, may have experienced the closest brush with losing all carriers on the exchange. Several insurers left the Arizona market in the summer of 2016, and it seemed likely that Pinal’s 402,000 residents would have no options when the exchanges opened in the fall. But in September, Blue Cross Blue Shield of Arizona agreed to offer plans for 2017.

Madison County, Illinois, is down to one insurer on Healthcare.gov. Last November, Mike and Nancy Cluck told St. Louis Public Radio about their frustrations with coverage and the Affordable Care Act.
Credit Durrie Bouscaren | St. Louis Public Radio
Madison County, Illinois, is down to one insurer on Healthcare.gov. Last November, Mike and Nancy Cluck told St. Louis Public Radio about their frustrations with coverage and the Affordable Care Act.

Jim Hammond, a Phoenix-based health care consultant, believes that change was the result of a behind-the-scenes campaign between Blue Cross and Banner Health Network, a major hospital chain.

“Blue Cross is very close with Banner. And Banner might have said to Blue Cross, 'Hey look — if you leave these people without coverage in our county where we have a hospital, we’re going to get killed,’” Hammond said. “At the end, Blue Cross kind of came to the rescue.”

Other states have taken a different tack.

In Alaska, state legislators approved a $55 million reinsurance plan to shore up its individual market. The funds went to Alaska’s last remaining carrier for the individual market, Premera Blue Cross, to help pay for the state’s sickest patients. Alaska applied for additional federal funds.

Afterward, the state’s only carrier on the individual market agreed to raise rates by 7.3 percent, after threatening a 40 percent increase.

Nevada’s attempt to offer public Medicaid coverage to all residents, regardless of income, was vetoed by the state’s governor last week. But the state’s insurance regulators have used the program as a bargaining chip to improve the individual market, said Sabrina Corlette of Georgetown University’s Center on Health Insurance Reforms.

“Nevada has basically told insurance companies that are participating in its Medicaid program that if you participate in the individual marketplaces, you’ll get favorable treatment on the Medicaid side, which is a very lucrative contract for many insurers,” Corlette said. “States have a lot of power to shore up these markets.”

One place for Missouri to start, Corlette said, would be to accept federal money to expand Medicaid coverage to low-income workers through the Affordable Care Act. 

Meanwhile, in Washington

Senate Republicans in Washington, D.C., are attempting to fast track a bill to overhaul the Affordable Care Act. Like their counterparts in the House, senators are using a process called budget reconciliation; a tactic that limits the changes they can make but requires only a simple majority to pass.

In a bid to avoid the public outcry in response to the House’s deeply unpopular proposal, senators have not been holding open hearings — a move that Democrats say is alarming and unprecedented.

“We have no idea what’s being proposed,” U.S. Sen. Claire McCaskill, D-Mo., told Senate Republicans on June 8. “We’re not even going to have a hearing on a bill that impacts one-sixth of our economy … I am stunned.”

GOP leaders say they’ll push for a vote before the July 4 recess.

This summer, insurance companies are submitting their rates for coverage they plan to sell in 2018. That means they’re making financial decisions about coverage next year, without knowing what’s going to happen politically. Analysts say that could mean higher rates, if companies feel like they’re really taking a risk by staying in the individual market.

Follow Durrie on Twitter: @durrieB

Copyright 2020 St. Louis Public Radio. To see more, visit St. Louis Public Radio.

Durrie Bouscaren
Durrie Bouscaren covers healthcare and medical research throughout the St. Louis metro area. She comes most recently from Iowa Public Radio’s newsroom in Des Moines, where she reported on floods, a propane shortage, and small-town defense contractors. Since catching the radio bug in college, Bouscaren has freelanced and interned at NPR member stations WRVO, WAER and KQED. Her work has aired on All Things Considered, KQED’s The California Report, and Harvest Public Media, a regional reporting collaborative.
Brent Jones is a journalist who works with data and design. He joined the St. Louis Beacon after graduating with a Bachelor of Science in Journalism from Southern Illinois University Carbondale in 2007. In the past five years, he has shot photos of the Pevely Dairy fire and flooding in Cairo, Ill.; compiled data on St. Louis' hottest days and whitest Christmases; edited a 30-minute video on music in Iraq; designed a 150+ page ebook; and produced audio from an improv show and more than 100 Beacon Roundtables. Jones lives in St. Louis, where he has completed a half- and full marathon and sings in a 16-member a capella madrigal ensemble.
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