By Jordan Shapiro and Walter Moskop

Jasmin Maurer was among nearly 150,000 Missourians who signed up for insurance during the first open enrollment under President Barack Obama’s health care overhaul.

She hadn’t been insured since she graduated from college in 2008 and her mother lost her job — along with her employer-sponsored coverage. Now Maurer had insurance for about six months, and it’s completely changed how she thinks about her health.

“If something bad happens, I know that I will not become homeless because of it,” she said.

Maurer is one of many consumers who’ve gained health insurance for the first time because of the Affordable Care Act. But many more still go without it, and significant challenges remain to reducing the uninsured rate. A Post-Dispatch analysis of enrollments on HealthCare.gov, the government’s online health insurance marketplace, shows where the campaign to expand coverage was successful, and where more work needs to be done when enrollment for 2015 begins on Nov. 15.

The analysis, which looked at private plan enrollments by zip code in Missouri and Illinois, indicates that urban and suburban areas had higher rates of marketplace sign-ups than rural locations.

“There’s a lot of misunderstanding in the rural areas about what this is,” said Ryan Barker, vice president of health policy at the Missouri Foundation for Health. “There’s just a lot of mistrust and hatred of Obamacare.”

The analysis also highlights key differences between the two states. In Illinois, the lowest-income areas had the lowest rates of sign-ups for private insurance, although many residents likely qualified for Medicaid, the federal-state insurance program expanded under the health law. In Missouri, areas with higher uninsured rates saw a larger number of enrollments in private insurance since that was the only option available to them.

“It really shows big gaps and opportunities for more enrollment,” said Cora Walker, a professor at the St. Louis University School of Law, who reviewed the analysis.

For those charged with helping residents enroll in health plans, the data show more needs to be done to bring coverage to historically uninsured populations, specifically African-Americans and Latinos who in Missouri represented only 9.3 percent and 1.6 percent of marketplace enrollment, respectively, according to the Missouri Foundation for Health.

“Everyone who is doing any kind of outreach needs to continue to do that,” said Nancy Kelley, a certified application counselor with the Missouri Foundation for Health. “There are people there who need to get the information and the plans in front of them.”

Last month, the federal government released data on the number of people who signed up for health plans by zip code. It doesn’t indicate whether those people are still enrolled and paying their premiums.

The data did not include zip codes where less than 50 people signed up for coverage because of privacy concerns. Although that exclusion meant there was no data for 40 percent of zip codes in federal marketplace states, those areas only accounted for 4 percent of overall marketplace enrollment.

The Post-Dispatch compared the number of sign-ups per zip code with U.S. Census Bureau projections on median incomes, population and percentage of people without health insurance.

Getting Covered

The U.S. Census Bureau estimates 773,000 Missourians and about 1.6 million Illinoisans did not have health insurance at some point during 2013, before the online government insurance marketplaces and expanded Medicaid coverage took effect.

The first enrollment period saw 152,000 people in Missouri and 217,000 in Illinois sign up, making a small dent in the number of uninsured.

Maurer, who works at a nonprofit agency that doesn’t provide employer-sponsored health insurance, was one of them. She signed up on HealthCare.gov and qualified for a subsidy to purchase her plan.

She said her only interaction with the health system after college was going to different federally qualified health centers when she needed care and paying based on her income.

“I just didn’t go to the doctor for a number of years,” she said.

Now she does. And while her marketplace plan doesn’t include vision care, Maurer said she was able to use the money she would previously have spent on primary care to repair her glasses.

It’s difficult to decisively conclude what individual factors led people like Maurer to sign up for health plans using the marketplace, and there were some surprises in the data.

In Missouri, there was significant marketplace participation in the southwestern part of the state around Branson, Nixa and Lebanon. Barker said that could be the result of a strong “ground game” of outreach and education there.

In the ZIP code that includes Lebanon (65536), 1,150 people signed up for marketplace coverage — a rate of 40 sign-ups per 1,000 residents. The uninsured rate for that area is 16.1 percent, and the median household income is $38,621.

The Medicaid Factor

Disparities in participation in private Obamacare plans between Missouri and Illinois are clearly illustrated in the St. Louis area.

Metro East,  for example, had a much lower enrollment rate compared with downtown St. Louis, even though the areas have similar uninsured rates.

A ZIP code that includes Sauget and parts of East St. Louis (62201) had only eight health plan sign-ups per 1,000 residents, despite having an uninsured rate of about 21 percent. That sign-up rate is significantly lower than those on the Missouri side of the metropolitan area.

But that doesn’t mean those Illinois residents didn’t get health insurance.

The differences between both sides of the Mississippi could be attributed to several factors, but the biggest is that Illinois expanded Medicaid under the health care law, while Missouri did not.

If someone qualifies for Medicaid, they would not need to buy a private marketplace plan; thus, their insurance status would not be reflected in the zip code data.

Although anyone can sign up for a marketplace plan, tax credits to help pay the cost are available only to people with incomes above the poverty threshold since the law's framers assumed they would be eligible for expanded Medicaid.  The law mandated that states offer Medicaid coverage to everyone making up to 138 percent of the federal poverty level, or up to about $16,100 for an individual. The Supreme Court, however, made that provision optional in 2012, and 23 states, including Missouri, have declined to participate.

The Sauget and East St. Louis zip code that saw low marketplace participation has a median income of $16,684, near the threshold to qualify for Medicaid for an individual.

Missouri lawmakers' refusal to expand the program left some Missourians with incomes too high to qualify for Medicaid, but still unable to afford coverage through the marketplace.

Many areas with high uninsured rates and lower incomes saw fewer sign-ups compared to places that were slightly more affluent, but had a similar uninsured rate. Having higher incomes means residents were more likely to qualify for a tax credit to buy a marketplace plan.

Data from two adjoining zip codes in St. Louis, divided in most places along Delmar Boulevard downtown, illustrate this point.

The southern zip code (63103) had 38 marketplace sign-ups per 1,000 residents, while the northern one (63106) had 22 signups per 1,000 residents, even though it had significantly lower income and a higher share of uninsured population.

Medicaid expansion is just one of the many challenges going forward.

Reaching the rural uninsured will be key. Kelley, of the Missouri Foundation for Health, said the organization plans to broaden its efforts by attending non-health care related events, such as football games or fairs.