By Jim Salter

The Associated Press

ST. LOUIS – 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 are 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.

Local shortcomings

Still, Jackson County has a higher rate of uninsured residents that the statewide average of 16 percent. In 2011, Jackson County had 582,498 residents under age 65, and 105,061 of them – or 18 percent – lacked health coverage. Among the 10 most populous counties in the state, that’s the third highest rate of uninsured, trailing the city of St. Louis (20.5 percent) and Jasper County, which includes Joplin, in southwest Missouri (20.4 percent).

Greene County, which includes Springfield, was at 17.3 percent, but the other six large counties were better than the statewide average, from Boone County, which includes Columbia (14.5 percent) to St. Charles County (9.9 percent). The three KC metro counties besides Jackson were all below the state average: Clay (13 percent), Cass (13.2 percent) and Platte (10.4 percent).

Dr. Bridget McCandless, president and CEO of the Health Care Foundation of Greater Kansas City and co-founder and medical director of the Shared Care Free Clinic in Independence said it’s hard to say if a lot of people locally are taking advantage of health exchanges to buy insurance since figures released so far are at the state level. Still, her own patients give at least a clue about where this is headed.

“What I’m surprised (by) is how many patients are aware of it, interested in it and looking into it. ... I’m thrilled,” she said.

Vicious cycle

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.”

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.”

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,

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, only 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.

The Examiner staff and AP reporter David A. Lieb in Jefferson City contributed to this report.