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Missouri, Illinois Health Insurance Exchanges Gear Up Quietly

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 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.

Related Topics

Cost and Quality States The Health Law Uninsured