JEFFERSON CITY — You won’t find Dwight Fine’s name on the Missouri state payroll. But the retired hospital association executive has been working for state government the last three years.
In health care circles, he’s known as the state’s Affordable Care Act coordinator. The Missouri Foundation for Health, a St. Louis-based nonprofit group, pays Fine’s salary and “loans” him to the state. He reports to the social services director.
Having an invisible coordinator is just one example of how the administration of Gov. Jay Nixon, a Democrat, has walked a political tightrope as the state gets ready for a federal initiative that the Republican-led Legislature strongly opposes and state voters have weighed in against — twice.
The keystone of the law — an online marketplace where uninsured consumers can buy insurance, often with federal subsidies — is shrouded in secrecy in Missouri.
Unlike some states, which have released detailed information about the proposed premiums that insurers will charge for policies sold through the exchange, Missouri won’t provide any hints.
Last November, Missouri voters overwhelmingly approved a law that barred Nixon from setting up the exchange without legislative or voter approval. As a result, the federal government will operate Missouri’s exchange.
Sen. Rob Schaaf, R-St. Joseph, championed the ballot measure and is a vocal critic of the federal Affordable Care Act, sometimes called Obamacare. Schaaf, a physician, said government shouldn’t expand the social safety net when the current system is broken.
“Is it the place of government to provide everything for everyone? I don’t think it is. What we really need to do is reduce the cost of health care by putting competition into the health care market,” Schaaf said.
Citing the voter-approved restrictions, the state’s top insurance regulator, John Huff, declined through a spokesman to be interviewed about the exchange, which makes its debut in seven weeks.
The state “is not participating with the federal government in the administration of the health insurance exchange that will be used by Missouri residents,” said Huff’s spokesman, Chris Cline.
In a chance encounter in a state office building stairwell on Monday, Huff added: “We’re in the lanes we’re allowed to be in.”
The state’s silence means Missourians won’t know anything about the affordability of plans offered through the new marketplace until federal officials release the details.
The Centers for Medicare and Medicaid Services has said that final certification decisions on the plans will be made by Sept. 4 and information will be posted on the healthcare.gov website after that. The exchange opens Oct. 1.
The information vacuum troubles advocates for the uninsured, as well as some staunch opponents of the law.
“I do think, unfortunately, that we’re going to have an unusually difficult time here,” said Jeanette Mott Oxford, executive director of the Missouri Association for Social Welfare, which lobbies for policies that help low-income residents. “There is a lot of confusion, and people are not getting enough information about it.”
Missouri is one of 19 states that ceded full control of its exchange to the federal government. Fifteen states are partnering with the federal government. Sixteen states and the District of Columbia are building their own exchanges.
U.S. Sen. Roy Blunt, R-Mo., a critic of Obamacare, called this week for federal officials to release the premium information by Aug. 26 in Missouri and the 33 other states where the federal government is involved in negotiating rates.
Blunt said families needed time to plan for insurance costs, which he contends will rise under the law.
However, in some states, such as New York, officials have said premiums for individual policies will drop. The analysis is complicated by the fact that policies offered through the exchanges will cover a wider range of benefits than most individual plans cover now.
Spreading The Word
Though they don’t know how much the new plans will cost, Missouri’s social services agencies and community groups that work with the uninsured are gearing up to spread the word about the exchange.
The Foundation for Health’s board is expected to vote next week to supply $1.1 million worth of posters, wallet cards and other promotional materials about the exchange. An additional $5 million in grants will be distributed to groups to hire “certified application counselors” to help with online sign-ups.
The information blitz is needed, said Tonya Cain, 40, a single mother from Cedar Hill, Mo. She is unemployed and needs insurance.
Cain relied on the emergency room at the SSM St. Clare Health Center near Fenton when she had severe abdominal pain. Afterward, she said, she “went scrapping” — picking up aluminum cans to sell — to pay for the pain pills and other drugs prescribed for a ruptured cyst on her ovaries.
She said she had no information about the exchange.
“I just know that everybody’s talking about Obamacare, that it’s supposed to start the first of January. That’s it. No more information, no brochures,” Cain said.
To add to the confusion, the goal posts keep moving.
The New York Times reported last week that President Barack Obama’s administration has delayed until 2015 a limit on how much people must spend in some group health plans on out-of-pocket costs, such as deductibles and co-payments.
The delay follows last month’s one-year delay in a requirement that larger employers offer health coverage to full-time employees.
An estimated 877,000 Missourians are uninsured. The federal law intended for them to gain health coverage either through Medicaid, the public insurance program for the poor, or the exchanges.
But the U.S. Supreme Court made the Medicaid expansion optional for states, and Missouri legislators rejected it. That will leave an estimated 226,525 Missourians below the poverty line without any type of subsidized coverage. About 350,000 people may be eligible for the federal subsidies.
Fine, the state ACA coordinator, said his role centered on the state’s transition to a Web-based enrollment system for Medicaid. Information typed into the federal exchange portal is supposed to automatically transfer to the state website if the person is Medicaid-eligible.
Obamacare opponents delayed the software changes for several years, leaving the contractor only four months to do the job before the Oct. 1 launch. Still, Fine said he was “reasonably optimistic” that the work would be done on time.
“It’s a tight timeline, but we have a clear sense of what needs to be done,” he said.