Fascinating

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The marketplace, or exchange, being established by the federal government under President Obama’s health care law has no visible presence here, no local office, no official voice in the state and no board of local advisers. It is being run like a covert operation, with no marketing or detailed information about its products or their prices.

While states like Colorado, Connecticut and California race to offer subsidized insurance to their citizens, Missouri stands out among the states that have put up significant obstacles. It has refused to create an insurance exchange, leaving the job to the federal government. It has forbidden state and local government officials to cooperate with the federal exchange.

It has required insurance counselors to get state licenses before they can help consumers navigate the new insurance market. And, like many states, it has refused to expand Medicaid.

“It’s like running an obstacle course every day of the week, but the course changes from day to day,” said Herb B. Kuhn, president of the Missouri Hospital Association, a strong advocate of expanded coverage.

State Senator Rob Schaaf, the Republican author of a 2012 ballot measure that prevented the state from setting up its own insurance exchange, said: “We can’t afford everything we do now, let alone provide free medical care to able-bodied adults. I have a philosophical problem with doing that, and I’m also worried about our country’s financial situation.”

Over 850,000 Missouri residents, including low-income people in St. Louis and Kansas City, family farmers and small-business employees, are uninsured. Many could qualify for coverage through the exchange, which encourages competition and offers subsidies to reduce costs.

Kenneth L. Schmidt, an insurance broker in St. Louis who intends to sell insurance products offered on the exchange, said: “We have not seen any evidence of the federal exchange — how it will be run, how it will be structured in Missouri. Will it be run from Jefferson City? Will it be run from Washington? Who will watch over it? No clue.”

David R. Griggs, who owns a carpet store with 15 employees in Columbia, Mo., said he was hungry for information about the exchange. But, he said, “I have not seen or heard a word about it.”

Kat Cunningham of Columbia, the president of Moresource, a firm that handles payroll and benefits for more than 600 employers, said she had been deluged with questions from clients and was struggling to provide guidance.

She said her clients wanted to know: “Where do we go to purchase health care coverage? How much will it cost us? If we can’t afford it, what then?”

Private foundations and community groups have stepped into the vacuum. M. Ryan Barker, vice president of the Missouri Foundation for Health, said his organization planned to spend $8 million this year on a campaign to secure coverage for 200,000 of the uninsured. “The state government is not doing a whole lot, its hands are tied, so we are taking on a bigger role,” he said.

Jennifer G. Bersdale, executive director of Missouri Health Care for All, a grass-roots organization, has been educating thousands of people about what she sees as an exhilarating prospect. “People who have been shut out of the market for years will soon be able to get good insurance, cannot be denied because of pre-existing conditions and can get financial assistance to afford it,” she said.

Missouri is one of a handful of states where the federal government directly enforces the consumer protections of the Affordable Care Act because the state lacks the authority to do so. In 2010, Missouri voters overwhelmingly approved a ballot measure expressing opposition to the federal requirement for most Americans to have health insurance.

In November 2012, voters approved a ballot measure that prohibits the governor and other state officials from establishing or operating a state-based insurance exchange unless authorized by a vote of the people or by the state legislature. The measure says state and local officials cannot provide “assistance or resources of any kind” to a federal exchange unless such assistance is specifically required by federal law. It authorizes taxpayers and state legislators to sue state and local officials who flout its restrictions. The threat of lawsuits has made local officials cautious.

Gov. Jay Nixon, a Democrat, said debate on the ballot measures had been highly political. He has held dozens of events to promote the expansion of Medicaid, stressing its economic benefits for the state. But Republicans hold two-thirds of the seats in each house of the legislature.

“A core principle of public health is to increase access to health care,” said Josephine P. Waltman, the health officer for Phelps County. But, she said, the ballot measure limits what local officials can do and is forcing them to consult lawyers.

As a result, Ms. Waltman said she and her staff would distribute general information about the insurance exchange, but would not sit down with people at computers to help them choose health plans and see if they qualify for subsidies. “I would love to do that,” she said.