More Than a Third of the Marketplace Patients Who Averaged Two Visits at One Kansas City Hospital Didn't Return in Fiscal 2026. A DPC Doctor There Advertises on a Billboard.

Industry News by DPC Insider — Research Desk
#Kansas City#ACA marketplace#uninsured patients#Medicaid expansion#safety-net hospitals#practice economics
Sources: Kansas City hospitals are seeing more patients without insurance — and expect many more · KC hospitals see more patients without insurance — and expect many more · Not accepting health insurance is a selling point for some KC doctors · Missouri Revised Statutes § 376.1800, Medical retainer agreements · Kansas — Direct Primary Care Frontier · Status of State Medicaid Expansion Decisions · How Many Uninsured Are in the Coverage Gap and How Many Could Be Eligible if All States Adopted the Medicaid Expansion? · Missouri Amendment 2, Medicaid Expansion Initiative (August 2020) · Adult Medicaid Expansion FAQs — Missouri Department of Social Services · How much and why ACA Marketplace premiums are going up in 2027

University Health, the safety-net hospital in Kansas City, went looking for patients it already knew. It took its patients on an Affordable Care Act plan who had averaged two hospital visits in fiscal 2025, then checked who came back in fiscal 2026. More than a third never did.

KCUR published the finding on September 14, carrying reporting The Beacon ran a week earlier. Of the 64 percent who did come back, 8 percent returned with no insurance. The hospital puts the combined revenue loss from the two groups at $37.5 million.

Seven days before that, the same newsroom published something that reads differently now. Kansas City doctors who don’t take insurance are advertising that fact as a selling point, one of them from a billboard on Troost Avenue.

What the $37.5 million is measuring

Start with what this figure is. It’s one health system’s look at its own patient records, not a study. No methodology was published, no confidence interval, no outside review.

The cohort matters more than the percentage. The patients in question had already been showing up about twice a year, which describes people with ongoing medical needs and an established relationship with the hospital. Absence in that group carries weight precisely because those people had a reason to return.

That’s also why the number doesn’t describe marketplace enrollees generally. It describes people who were already using the hospital.

“Did not return” can’t separate the reasons either. A patient who found a job with employer coverage and now goes to a different health system counts the same as one rationing care at home. So does anyone who moved out of the metro, and anyone who simply got well. The hospital reads its own data one way: a spokesman told the paper that “if and when these patients return, we anticipate they will come back to us with more serious illnesses since they have been skipping all of their appointments.”

And the $37.5 million is revenue. It measures what the hospital lost, which is a real thing to measure and a different thing from what the patients lost.

The state line runs through the middle of this

Kansas City sits on two states, and they’re pulling apart.

By February, marketplace enrollment in Missouri was down 25 percent year over year to 260,999 people. Kansas fell 20 percent to 143,880. The enhanced premium tax credits that had held those prices down expired at the end of 2025. Among the insurers that adjusted for that expiration, the Peterson-KFF Health System Tracker reports, projections put 2027 premiums roughly four percentage points higher than they would otherwise have been.

January adds a second mechanism. Under the new federal law, adults covered through Medicaid expansion have to document work, school or volunteering and recertify every six months instead of once a year.

That requirement finds a population on one side of the metro and not the other. Missouri voters put expansion in the state constitution in August 2020 and the state began processing those applications in October 2021, so Missouri has expansion enrollees for the new rules to reach. Kansas remains one of the ten states that never expanded. Kansans who fall between the two programs land in what KFF calls the coverage gap, with incomes too high for their state’s Medicaid program and too low for marketplace subsidies.

The University of Kansas Health System isn’t waiting to find out how it lands. Colette Lasack, who oversees billing for the $5.4 billion system, told the paper she worries about every patient who walks through the door without insurance. The system has 55 financial counselors on staff and is considering adding more.

What the clinics are selling

Kansas City has had direct primary care for a while. Dr. Damon Heybrock opened Health Studio in Westwood about ten years ago, among the first practices in the metro to run on memberships instead of claims. Dr. Myriam Ensling, an internal medicine physician, is actively marketing her clinic to people who lack insurance, including from the billboard on Troost Avenue.

Both sides of the state line allow this. Missouri’s 2015 medical retainer agreement law sits at Mo. Rev. Stat. § 376.1800, and Kansas codified its version at K.S.A. § 65-4978. The Missouri statute says a medical retainer agreement “is not insurance” and that a provider needs no certificate of authority to sell one, which is what lets a physician offer memberships without an insurance license.

On price, The Beacon puts these memberships at roughly $80 to $100 a month, with the flat monthly fee averaging about $80 in the Midwest. Costs vary by practice, by location and by what a given membership covers, so treat that as a range rather than a rate.

For someone who just watched a subsidized premium reprice, a predictable monthly number is a real thing to be able to say out loud. It also isn’t coverage. The Beacon reports critics warning that the model isn’t a replacement for insurance, since it covers basic care rather than hospitalizations, lab work or specialists. Many of the patients who enroll carry health insurance as well.

The Counterargument

The strongest case against reading this as a limit on DPC is that the hospital already named the mechanism, and DPC sits right on top of it. The patients University Health is worried about are skipping appointments. Appointments are primary care. Many of these practices offer unlimited visits for a flat monthly fee, and for a member of one, the cost of the next visit stops being a reason to skip it. If deferred primary care is what turns a manageable year into a hospitalization, then a membership interrupts that sequence at the cheapest point anyone could interrupt it.

That argument is sound, and it covers a narrower group than it first appears. It works for people who can pay a monthly fee, which excludes the Kansans in the coverage gap almost by definition, since being in the gap means earning too little for subsidized marketplace coverage. A membership is one more bill for that household.

So the claim survives with its scope corrected. Direct primary care can catch some of the people falling out of marketplace coverage in Kansas City, and it can catch them at the layer where deferral is cheapest to prevent. It can’t catch the hospital course that follows a skipped year, and it can’t recover the $37.5 million. What the metro is running right now is two experiments at once, on either side of a state line, and neither newsroom has the instrument to say whether the same people appear in both.