Declining Medicaid enrollment in Missouri has advocates concerned

Jun. 16--A large number of Missourians have been dropped from the state's Medicaid program over the past year and a half, despite remaining eligible for services, according to health care advocates.

Data publicly available from the Missouri Department of Social Services indicates more than 101,000 people, including more than 80,000 children, have left Medicaid coverage in Missouri, where the program is called MO HealthNet, from June 2018 through last month. That's a drop of about 10.45% and a decrease in child enrollment of more than 13%.

Missouri residents also appear to be leaving Medicaid at rates higher than the rest of the country.

During a slightly different time period, from May 2018 to February of this year, total national monthly enrollment in Medicaid and CHIP, the Children's Health Insurance Program, dropped from 74 million to 72.2 million, a decrease of 2.42%, according to information from the Henry J. Kaiser Family Foundation.

Total Medicaid enrollment in Missouri dropped 7.52% during that same time period, from 973,358 to 900,186, according to the state.

The drop in the number of children from Medicaid services was more pronounced. Nationally, monthly child enrollment in Medicaid and CHIP decreased 2.09% in that time frame, while the number of children on Missouri's rolls dropped more than 9%, according to the data.

"That just doesn't add up," said Jen Bersdale, executive director of Missouri Health Care for All, a nonprofit and nonpartisan statewide organization that seeks access to affordable, quality health care.

National trends

It's an issue that national groups are watching in several states across the country.

About 828,000 fewer children nationwide were enrolled in Medicaid and CHIP at the end of 2018 from the prior year, according to a new report from the Georgetown University Center for Children and Families, an independent, nonpartisan policy and research center. That drop, the center said, was "unusual." Between 2000 and 2016, child enrollment in those programs increased or held steady in all but one year.

The report also notes that the enrollment declines in 2018 were the most concentrated in seven states, including Missouri.

"The fact that nearly 1 million children in 38 states lost Medicaid and CHIP coverage is very alarming," Joan Alker, the center's executive director, said in a statement. "This report puts federal and state policymakers on notice that the success the U.S. has achieved on children's health coverage is in jeopardy. Federal and state leaders must acknowledge the problem, investigate its causes and take immediate action to ensure children have the health coverage they need to succeed."

Those who work with Medicaid clients in Missouri say they believe people are being unfairly dropped from the state's rolls because of an inefficient renewal system that went into operation last summer.

Under the Affordable Care Act, states can verify Medicaid clients automatically if nothing from the individual, such as food stamp eligibility or income level, has changed, said Joel Ferber, director of advocacy for Legal Services of Eastern Missouri, which provides free legal assistance to low-income individuals and the elderly. Medicaid renewal for clients typically occurs every 12 months.

But Missouri's Medicaid renewal system isn't set up to do automatic renewals consistent with federal requirements, Ferber said. Instead, the state is still sending out paper packets to clients and, in many cases, allegedly not checking client data that has already been submitted for Temporary Assistance for Needy Families, the federal food stamp program, he said.

That means there can be a breakdown in the renewal process, potentially leading to clients inadvertently being dropped from Medicaid when they would otherwise still be eligible, he said.

"The biggest part of the problem is they (the state) are not doing the no-touch renewal to the extent they can," said Ferber, referring to a system that allows for automatic renewal of clients. "We're convinced this is all related to the renewal process."

In response to questions sent by the Globe to the Missouri Department of Social Services, a spokesperson emailed copies of letters the department had sent to state Rep. Crystal Quade, D-Springfield, and state Sen. Scott Sifton, D-St. Louis County, following their queries into Medicaid.

The letters say that the department's Family Support Division attributes the decline in caseloads in the state's Medicaid program to "an improving economy in Missouri; the decreased emphasis on the federal marketplace open enrollment period and the repeal of the individual mandate; (and) new technology (that) allows the state to better track and issue annual reviews."

"Please know that the FSD (Family Support Division) is committed to conducting eligibility determinations for the MHD (Medicaid) program in a way that is fair, efficient and transparent for the people of Missouri, while ensuring that the division continues to fulfill the vitally important mission of the Medicaid program," wrote Patrick Luebbering, director of the division, in a March letter to Quade.

'Literal desperation'

Joplin resident Heather Wright says it was a system issue that resulted in her mother temporarily losing Medicaid services last summer. The 28-year-old helps manage Medicaid for her mother, 55-year-old Serina Wright, who has Friedreich ataxia, a rare disease that causes progressive nervous system damage and movement problems.

The elder Wright has battled the disease since she was young, and for two decades, Medicaid has covered her hospice care, surgeries, medications and doctor visits, her daughter said.

"She couldn't live without it," Heather Wright said.

But last summer, her mother unexpectedly received a letter in the mail notifying her that she had lost her Medicaid services. When Heather investigated at the local Medicaid office, she was told that there had been a "filing error" with her renewal papers.

Heather filed with the Missouri Department of Social Services to reinstate her mother on the Medicaid rolls, citing her case as "high priority." Time was of the essence, she said -- she had been told that if her mother could be re-enrolled within a month, the state would reimburse services used during that time.

She said she called the state department daily to check on her mother's application. It was only when it was finally approved, and her mother was back on Medicaid, that she felt relief.

"It was through literal desperation that I was able to get her Medicaid back," she said. "It was like jumping through hoops. It was probably one of the most stressful times of my life."

Heather now spends every day scouring her mailbox in case her mother receives another letter like she received last summer. But she hopes she doesn't have to, and she worries about those who no longer receive Medicaid but who might depend on it.

"They can't afford to lose those services that the government is providing," she said. "My mom wouldn't be able to live without those services."

Advocates including Ferber and Bernsdale say implementing a fully functional automatic renewal system in Missouri would be the best solution, ensuring that Wright's mother and others like her would keep their Medicaid services as long as their eligibility remains in place.

Bernsdale also urged the state to temporarily stop automatically dropping people from Medicaid until their cases have been manually reviewed.

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