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[MM Curator Summary]: Long delays in application processing may be behind the lower-than-expected uptake of expansion in the Show Me State.
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Updated January 25, 2022 11:03 AM
In this October file photo from Mountain View, Mo., Carolyn Hayes, 55, answers questions from Good Samaritan Care Clinic volunteer Vicky Medley, a retired Department of Social Services employee, to fill out an application for Missouri’s expanded Medicaid program. Outreach work to get low-income adults enrolled has fallen to grassroots organizations and clinics serving the poor. Jeanne Kuang/The Kansas City Star
As soon as the Missouri Supreme Court ruled last July that Medicaid expansion must go forward, Amanda Leach applied.
The 29-year-old southwest Missouri woman and her husband had both been uninsured for years, making too little to afford private insurance, but too much to qualify for Medicaid under the old rules. The new eligibility guidelines, approved by Missouri voters in August 2020 after years of opposition from lawmakers, allowed adults in a family of five to qualify if they earned up to $42,800 a year.
Leach, who has three children, was eager to get coverage for the corticosteroids used to treat her asthma. She could only afford refills during the months she qualified for Medicaid while pregnant. When she showed up at an urgent care center with COVID last July, struggling to breathe, she refused to be hospitalized for lack of insurance.
She ended up waiting nearly four months for Medicaid.
“I couldn’t even tell you how many hours I spent on the phone” checking the status of her application, she said. The state lost her proof of income twice during that time.
Missouri didn’t start officially processing applications for expanded Medicaid until October, partially explaining the delay.
But four months into the program’s official start, long waits like the one Leach faced are increasingly common.
Last month it took the Department of Social Services an average of 70 days to process a Medicaid application, a nearly ninefold increase from a year ago and well past the 45-day maximum set by federal law.
The department says it faces staff shortages as applications pile up. The division that processes applications saw a 20% turnover last year and a more than 70% decline in job candidates, DSS spokeswoman Heather Dolce said in an email. DSS is paying overtime and shifting workers’ assignments to keep up with “a large volume of applications and calls at this time,” Dolce said.
This month, officials told the House Budget Committee, nearly 70,000 Missourians who applied for expanded Medicaid were waiting to find out if they had been approved – more than have been enrolled.
The delays are the latest hurdle in what advocates have criticized as a slow and rocky launch of the expansion.
“Is it going at the appropriate pace? The answer is emphatically no,” said Sheldon Weisgrau, vice president of health policy for the Missouri Foundation for Health. “It is going much slower than anybody anticipated.”
Voters approved the expansion in a constitutional amendment in August 2020. But after lawmakers refused to fund it, Gov. Mike Parson nixed the planned July 1 launch last year. A judge ordered the state to expand the program anyway, but Parson’s administration delayed the start date to October to prepare for the influx of applicants. Full funding for the expansion, including the cost of 55 new employees to determine applicants’ eligibility, still hasn’t been approved by the legislature.
Since October, Missouri has enrolled more than 58,000 newly eligible adults in the program.
That’s well short of signups in Oklahoma, which also expanded Medicaid last year after voter approval. There, the state opened up applications before the planned start date and had 113,000 enrolled in the first month.
It’s also short of Missouri’s own projections. As it prepared to implement the program last year, Parson’s administration estimated that in the fourth month of expansion, Missouri would be covering more than 192,000.
Lack of awareness is one factor hampering full enrollment of the roughly 275,000 low-income Missourians the state expected to gain coverage under the expansion, according to health advocates.
The delay and subsequent court case likely confused people who may be eligible, they say, making local, grassroots outreach efforts particularly crucial.
DSS said the department has updated its website, social media platforms and email newsletters with information about the expansion. But advocates say the agency has failed to reach much of the low-income population that could qualify.
“There hasn’t been any real outreach to speak for from the state,” said Timothy McBride, a health economist at Washington University in St. Louis and former chair of the state’s Medicaid oversight committee.
Instead, much of that work is dependent on low-income clinics or other organizations that serve the poor.
Rates of enrollment appear to vary across the state, according to DSS data from the first three months of expansion that Washington University researchers have analyzed.
In some counties, as many as six or seven percent of the low-income adult population that could qualify have been enrolled. The two counties with the state’s highest rates of uninsured adults are lagging behind. McDonald County has only enrolled 3.3% of its low-income adult population, while Scotland County has enrolled 2.7% — just 34 people.
“My hunch is the variation’s reflective of how well people on the ground are doing in enrolling people,” McBride said.
At Scotland County Hospital
in northeast Missouri,
a staff member was trained to help patients sign up, in preparation for the expansion. But hospital officials said worker shortages have forced them to send patients to the nearest DSS office.
“We don’t have the horses to pull the cart when it comes to just medical care,” said CEO Randy Tobler, an advocate of expansion for the benefits it could bring to his patients and to struggling rural hospitals. “We’ve not been able to do outreach … Frankly, we’ve just put that on the back burner.”
Advocates say there are ways the state could more easily enroll large numbers of people who are now eligible for health care: by finding Missourians who already receive other social services.
Leach, for example, is no stranger to DSS, which checks her and husband’s income regularly because their three children have always qualified for Medicaid.
States like Louisiana have used income data from the Supplemental Nutrition Assistance Program, or food stamps, to enroll eligible residents without requiring their application.
In Missouri, that hasn’t happened. DSS “can only determine adult expansion eligibility if an application for healthcare coverage is received or an individual is found to be ineligible for another Medicaid category,” Dolce said.
The state is automatically moving some health care recipients from other programs to the expanded Medicaid. It has a financial incentive to do so. The state pays only 10% of the costs for recipients in the expanded program, compared with about 35% for other Medicaid beneficiaries.
Of those currently enrolled, Family Support Division director Kim Evans told lawmakers this month, about 27,000 are women who had been receiving family planning coverage under a separate state program.
The recent delays in application processing have created a dilemma for advocates who are trying to get more people enrolled, Weisgrau said.
“Ideally, you want to be out there waving the flag for this and beating the drum and letting people know what’s available,” Weisgrau said. “But when all you’re doing is putting people into a queue that takes more than two months for them to find out if they’re eligible, it creates a real problem and a lot of those people get frustrated.”
Applicants who haven’t heard back might give up on an application, or apply more than once, adding to the backlogs, Weisgrau said.
In October, a slip and fall landed Leach in the hospital with a broken calf bone and crushed ankle. By the time the bill arrived about a month later, she was finally approved for coverage. But the cost of her ER visit and surgery still caused a brief panic. Without Medicaid, she would have owed the equivalent of 18 months of mortgage payments.
She works in homeless outreach at a Springfield church, The Connecting Grounds, where she and a colleague have helped more than 100 people apply.
Even with use of the church’s computers, the application process and wait times can be challenging for people living in poverty who don’t have reliable Internet, phone service or even a permanent address, she said.
If they get locked out of the state’s online application they have to mail or fax their proof of income. If there is a question about their application they can’t always be reached.
“When I was trying to get through, the shortest wait time I had (on the phone) was three and a half hours,” Leach said.
“You don’t have the time to do that if you’re buying (cell phone plans) by the minute. And they can’t get hold of you about stuff when you never know if your phone is going to be on or if you’re going to have cell service. So that has been a very huge barrier for a lot of our folks.”
This story was originally published January 25, 2022 10:34 AM.