Missourians who live in rural areas are far less likely to have health insurance than those living near big cities, according to U.S. Census data.
The Associated Press examined county-by-county data for 2011, the most recent year available. The data is for residents under 65 since older residents are eligible for Medicare.
Missouri overall ranks right in the middle of the nation in the percentage of uninsured residents — tied with Washington state at 25th with 16 percent uninsured. But in 34 of Missouri's 115 counties (St. Louis city is considered a county for statistical purposes), one-fifth to one-quarter of non-senior residents lack health insurance. Twenty-seven of those 34 counties have fewer than 25,000 residents.
Health care leaders in Missouri are anxious to see if President Barack Obama's health care reform will drive down the number of uninsured, something it is designed to do both through an expansion of Medicaid and with new health care marketplaces that allow people to shop for private coverage and apply for government aid to pay premiums.
McDonald County in the far southwest corner of Missouri has an uninsured rate of 25.1 percent among its nearly 20,000 non-senior residents, the highest rate in the state.
It isn't that jobs are scarce — the county's jobless rate of 5.4 is better than the state or national average. It's just that most jobs in the county don't provide health care, said Keith Lindquist, presiding commissioner for McDonald County.
"What we have in this county are a couple of poultry plants," Lindquist said. "We love them because if it wasn't for them we wouldn't have a place to work, but they really don't have a very good (health insurance) program for anybody."
The problem isn't confined to southwest Missouri. The other counties in the top five for the highest percentage of uninsured residents include Hickory County in west-central Missouri (24.5 percent uninsured), Knox County in the far northeast corner (24.2 percent), Ozark County in south-central Missouri (23.7) and Sullivan County in north-central Missouri (22.4).
Karen Edison, director of the Center for Health Policy at the University of Missouri in Columbia, said cities and suburban areas attract larger employers, and the bigger companies are more likely to provide health care coverage. The state's nine counties with the best rates of insurance coverage are all in suburban St. Louis, suburban Kansas City or in mid-Missouri, where many people work for the state in Jefferson City or at the University of Missouri in Columbia.
Edison said the problem in rural areas is worsened by the fact that the blue-collar work is often more physically demanding, which can take a toll on workers' health. For those without insurance, taxpayers are left to foot the bill when medical needs arise.
"They break their bodies down," Edison said. "They have no preventative care, no primary care. It's a lose-lose for taxpayers and patients."
Page 2 of 2 - Brandy Smith, 34, has a college degree and works three jobs in McDonald County to make ends meet — she's a secretary for a real estate firm and a construction company, and a health educator for the county. None of the jobs provide health insurance for part-time workers, leaving Smith and her two young children uninsured.
She was hospitalized with pneumonia for three days last year. A charity program picked up the $12,000 cost, but she knows she might not be so lucky next time around.
"It really gave me the awakening that I needed health insurance," Smith said. "It's very scary."
Aaron Barnard, 39, owns his own construction company in Pineville, a small town in McDonald County. His wife and two kids are covered under her insurance plan. He could be added to her plan, too, but the cost is too much, he said.
"I do think about what could happen," Barnard said. "I figure I'll worry about it more when I turn 40. Sometimes it's just hard to let go of that money."
Nationwide, Texas has the highest uninsured rate at 25.7 percent, followed by Florida (24.8), Nevada (23.8), New Mexico (23.0) and Oklahoma (21.8). Massachusetts had the lowest uninsured rate at 4.9 percent.
Missouri, like 35 other states, opted not to set up its own online insurance marketplace as part of the Affordable Care Act, instead deferring to the federal system. The marketplace is intended to help people without employer-sponsored health insurance find coverage at affordable rates. The exchanges can also be used by small businesses.
Enrollment opened Oct. 1, though error messages and bugs in the system initially kept many people from being able to participate. The Obama administration has sought to make improvements to the website, HealthCare.gov.
Partly due to the website problems, enrollment has been lower than what some people expected. Missouri has about 800,000 uninsured residents; as of Nov. 30, 4,124 had enrolled.
"That's not a really great number, but it's a step in the right direction," said Thomas McAuliffe, policy analyst at the Missouri Foundation for Health.
"We remain optimistic about the possibility for the marketplaces," McAuliffe said. "We know that optimism is tempered by getting more people to take advantage of the opportunities that exist."
Edison said time will tell whether the Affordable Care Act is successful, but she said it is clear that changes need to be made to get health insurance to more people.
"We really need to transform our health system," Edison said. "We need to improve access for people who don't have it, we need to improve the quality we deliver, and we need to constrain our costs."