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Missouri faith leaders

Faith leaders gathered on the steps of the Cole County Circuit courthouse on Monday, August 15, 2016 to call for Medicaid expansion. They gathered before jury selection began for 23 clergy members facing charges after a 2014 protest led lawmakers to suspend the state Senate session. 

One of the signature accomplishments in recent years has been the remarkable decline in the number of uninsured Americans to a historic low. This has occurred even in Missouri, a state that did not expand its Medicaid program, where the uninsured rate fell from 13% in 2013 to 9.1% in 2017.

But in the last 18 months, this progress has come under threat as the number of people enrolled in the state’s Medicaid program fell by more than 119,000 from January 2018 to June 2019, a drop of 12%. Most alarming, the number of children covered by Medicaid has dropped by almost 95,000 in Missouri, a 15% drop — the steepest decline in the nation among children.

What is causing it? State leaders point to an improving economy, presumably concluding that former Medicaid recipients are obtaining jobs and no longer eligible for Medicaid. While it is clear that the state has a strong economy with a very low 3.3% unemployment rate, nearly all the evidence points to other reasons for the enrollment decline, especially among children.

First, and perhaps most important, children are eligible for Medicaid coverage in Missouri if their family’s income is less than 300% of the poverty line, about $62,300 annually for a family of three. While the economy has improved, it is highly unlikely that low-income parents (mostly single mothers) would have seen their incomes jump to over $62,300 in a matter of months, especially in an economy where there is significant income inequality.

Moreover, analysis of Missouri Medicaid enrollment data shows that essentially all of the children who were previously covered by Medicaid had family incomes less than 150% of the poverty line (roughly $32,000 for a family of three) before the family lost coverage in recent months. This means that we must believe that essentially all of the children who have lost Medicaid coverage are in families that saw their income more than double in just the past few months.

Missouri unemployment rates started declining in mid-2010, as in almost every other state, as the recession eased. Shouldn’t Medicaid enrollment have started declining then as well? And shouldn’t this have been happening in every other state, or at least every other state that has not expanded Medicaid?

What else might explain the enrollment decline?

Reports to the Medicaid Oversight Committee point to a process called “recertifications” as the reason. Starting in mid-2018, thousands of individuals (10,000 to 16,000 per month) were notified by mail that they needed to respond to written correspondence from the state if they want to keep Medicaid. This is where the process broke down.

Many people did not have a current address in the state’s computer system. Those who received the letter may not have understood it. Some appear to not have understood that a non-response would lead to losing Medicaid coverage. The state did what it could to contact, and recontact people (sometimes numerous times), but this process still may have broken down.

If the recipients needed help responding, the main way they could obtain assistance was to use one of the state-funded “call centers” (a private sector vendor paid from state funds). Reports are that the response rate to Missouri’s Call Centers are among the worst in the U.S., with very long wait times, averaging 45 minutes or longer, and with the calls sometimes being dropped.

Thus it seems likely that enrollment declines are linked to the recertification process itself and specifically because of unique aspects of Missouri’s systems. We have not invested in the computer updates to improve this process, nor the staff to improve the process over time. And, worse, we have outsourced much of this work to private sector vendors who have not adequately done the work.

The result: More than 100,000 people are no longer on the Medicaid rolls, and if they have not obtained other insurance coverage, they are likely to be uninsured. We know from a great deal of research that this means that when they get sick they will be more likely to delay obtaining medical care and if they do obtain the care they will be more ill and the costs will be higher.

Evidence suggests that covering children is not that expensive, and the long-term effectiveness of paying for prevention early in a child’s life can lower costs later in life, raising their well-being and income potential. Missouri voters should be quite concerned about 95,000 low income children without access to medical insurance.

Timothy McBride chaired the MOHealthNET Oversight Committee from 2012-19. He is a health economist and co-director of the Center for Health Economics and Policy at Washington University.