Applying for health insurance through Medicaid expansion took Raven Cole just 10 minutes. But the wait to see if she’s approved has dragged on for months.
Cole, 23, a legal assistant, applied for coverage “well over two to three months ago.”
“And I haven’t heard anything back,” Cole said.
Cole is one of 72,657 Missourians who had Medicaid applications pending as of January, according to the latest state figures. That month, the average time it took to process applications increased to 99 days — more than double the 45 days allowed under federal law.
After the courts ordered the state to enroll anyone who was eligible for health care under voter-approved Medicaid expansion, Missouri has lagged behind other states in getting applications processed.
State officials have repeatedly pointed to staffing shortages as part of the reason why, and have promised wait times will decrease.
“We’re committed to pulling every lever we can to bring those processing times back within that 45-day window,” Todd Richardson, MO HealthNet division director, told lawmakers earlier this month, “and expect that we’ll start to see some momentum on that in the coming weeks.”
But advocates and experts point to a variety of additional strategies Missouri could be employing to increase the speed of processing applications.
“We are clearly behind where we said we would be at this point in terms of enrollment,” said Timothy McBride, a health policy analyst, professor at the Brown School at Washington University in St. Louis and former chair of the MO HealthNet Oversight Committee.
Helping residents apply and navigate the long delays has largely fallen to advocates, who have set up helplines and workshops to help make a confusing process more accessible.
“All of these issues are just adding up to probably one of the worst rollouts we’ve seen,” said Angela Brown, CEO of the St. Louis Regional Health Commission.
As the state tries to work through its backlog, the end of a federal public health emergency looms that has allowed residents to maintain their Medicaid coverage through the pandemic. Experts warn that Missouri is one of the states where children are most at risk of losing their health care coverage when the emergency designation ends, in part, because of administrative hurdles.
Waiting for coverage
Since 2019, Cole has had health insurance through Gateway to Better Health, a temporary program for uninsured adults in St. Louis city and county who don’t qualify for Medicaid.
Because Missouri already had Cole’s information through Gateway to Better Health, she assumed the state could easily transfer her to Medicaid now that she qualified.
“I definitely didn’t expect for it to take this long, or to be this worrisome,” Cole said, “because I already was a patient of the state, basically.”
The Regional Health Commission administers Gateway to Better Health, and Brown had also hoped for a seamless transition. But a request to automatically move eligible Gateway to Better Health recipients onto expanded Medicaid was denied, Brown said, “and so we’re even having to go through a redetermination process with our population.”
It’s an example of how more comprehensive health care insurance has been delayed for thousands of Missourians as people’s eligibility is re-verified.
The department has taken a similar approach with applications received through the federal marketplace. Instead of accepting the information already contained in those applications and putting those eligible on a “fast track” to get them coverage, McBride said he had been told the department was going through each application individually.
“So the way I might describe it is… we’re not going to presume they’re innocent and put them on the program first,” McBride said of the state’s mentality. “We’re going to say, ‘Show me the data.’”
During a Feb. 3 MO HealthNet Oversight Committee meeting, Family Support Division Director Kim Evans said the department makes those checks, “because it may be just the children that are eligible, it may be just one of the parents that’s eligible.”
Meanwhile, applicants including Cole are waiting anxiously for the day they are enrolled.
“I don’t want to not have insurance and be in a predicament where I need to go to the doctor or urgent care,” Cole said, “and I’m worried that I will have to pay out of pocket and can’t afford it.”
Currently, Gateway to Better Health doesn’t have a set end date as recipients wait to see if they can transition to Medicaid expansion. It’s allowed Cole to still have some form of health insurance while she waits, but it’s already caused confusion. At a recent dental visit, her provider wasn’t sure if it would be covered through Gateway to Better Health or through Medicaid retroactively.
Strategies to improve
It’s not the first time Missouri’s Medicaid applicants have faced lengthy delays. It’s been a perennial problem for the department.
In 2014, Missouri’s Medicaid program was plagued by monthslong waits over processing issues and holds nearly an hour long through a contracted call center.
In January 2014, the average time it took for applications to be processed reached 97 days. That year, a majority of applications took over a month to process, according to state figures.
After treating the issue “as a short term crisis that they needed to deal with,” McBride said, wait times eventually dipped under 45 days the following year.
Those decreases haven’t yet been seen for the backlog in the wake of expanded Medicaid.
At the heart of the problem is the state’s customer service call center, where applications are processed and phone calls are answered regarding a variety of benefits — including Medicaid, temporary assistance and food stamps. The Family Support Division within DSS operates the center.
However, during the February oversight committee meeting Evans said all of the center’s Medicaid application calls were currently being directed to a “contracted call center.”
“They have had staffing issues about the time that we had volume of applications, and that’s contributed to the longer hold time,” she said, later adding: “As long as they don’t have anyone not show up for work, they should be fully staffed again by the middle of February and should be able to handle the call volume then.”
DSS has spent hundreds of thousands of dollars on various temporary staffing companies in fiscal year 2022. However, it’s unclear how many personnel or funds have been spent to augment the center’s staff and assist Medicaid applicants.
Even with temporary staffing issues — some that were related to the winter spike in COVID cases — Missouri is far behind other states that recently expanded Medicaid.
Other states enrolled half of their newly eligible residents within the first month. In nearly five months, Missouri has enrolled less than 25% of the estimated 275,000 eligible, with nearly 62,300 enrolled under Medicaid expansion as of January.
“We’re in the middle of a perfect storm,” Evans said during February’s oversight meeting of the factors contributing to the state’s delays.
Anticipating the high number of applicants, other states opted to automate parts of the process.
Louisiana was the first state to use an option offered by the federal government to determine enrollment for Medicaid and CHIP using SNAP income eligibility criteria — reducing paperwork for both state workers and program participants, according to a 2020 report by Washington University’s Center for Health Economics and Policy.
“Through this information-sharing process, Louisiana was able to avoid duplicative paperwork for many of the 235,000 new Medicaid enrollees when it expanded Medicaid in 2016,” it stated.
That’s not the case in Missouri, said Katherine Holley, an attorney for Legal Services of Eastern Missouri, which serves low-income clients.
“Someone could fill in a SNAP application and a Medicaid application on the same day,” Holley said. “That data is entered by two different people into two different computer systems. And they don’t communicate with one another.”
Evans said during the oversight committee meeting that DSS launched a single application for Medicaid programs in July.
The state had previously planned to launch a streamlined application to allow recipients to apply for multiple benefit programs, including SNAP and Medicaid, at once. But officials worried the new application would be lost amid the changes happening with Medicaid expansion, and previously said it would be launched early this year instead.
A spokeswoman for DSS did not respond to a request for comment Monday on the status of the application.
“I think eventually it’ll help,” McBride said, “but right now it’s part of the whole fog of confusion that’s leading to all this.”
Nia Sumpter, 26, didn’t have help applying for Medicaid coverage at a time when she needed it.
In December, Sumpter, a graduate student, spent roughly a month in the hospital to recover from sepsis. Sumpter, who has insurance through her graduate program, said she was told she couldn’t receive assistance applying for Medicaid through the hospital because she was insured. Sumpter’s university insurance still leaves her on the hook for large medical bills, and it will expire when she graduates from her master’s program in May.
It wasn’t until after she was discharged in early January that she was able to apply for Medicaid expansion — and even then it was a difficult process to navigate.
“Wow, I was confused. The language is so inaccessible,” Sumpter said, later adding: “Why couldn’t you just tell me, ‘Sign here, sign here and your health care will be covered, because as a human being we care about you.’”
For others, including patients of a free health care clinic in southern Missouri, many hadn’t heard that Medicaid expansion was an option they could apply for until the clinic told them and encouraged them to sign up.
Its hurdles advocates are working to overcome as they’ve largely taken over the groundwork of connecting eligible residents with assistance and resources to apply.
Prepare STL, a grassroots COVID-19 education campaign that worked to address inequities in the St. Louis region’s pandemic response, aims to broaden their work to impact health inequities more broadly. Brown, who is among the leaders in the campaign, said that includes helping residents apply and access Medicaid expansion so “they feel more confident in our healthcare system than they have before.”
Sumpter, who chairs the Regional Health Commission’s patient advisory committee, has been waiting for over two months on whether her application was approved. Sumpter has sickle cell disease, and getting the care she needs has long been a frustrating ordeal, from feeling like her experiences aren’t being taken seriously by healthcare providers to seeing firsthand how “all health insurances aren’t created equal.”
Receiving coverage under expanded Medicaid would help relieve the stress of worrying about expensive medical bills and help her focus on supporting her family, including her three-year-old son Zacheriah.
“I don’t get everything that I necessarily want, but I have everything that I need,” Sumpter said. “Whereas, I see family and friends who aren’t approved for Medicaid where they really go without their needs being met. And that is just egregious.”
As the state struggles to work through its current backlog of Medicaid applications, advocates are concerned the looming end to the federal declaration of a public health emergency may cause even more administrative issues.
In January, the emergency was extended for another 90 days through mid-April. Federal officials have previously said they would provide states with 60 days’ notice ahead of any termination.
Because of the federal emergency declaration, Missourians have been able to continue to receive health care coverage through MO HealthNet amid the pandemic — even if their circumstances may have changed and they no longer qualify for benefits.
But once the emergency ends, the state will begin the process of redetermining participants’ eligibility. Those who don’t qualify for another program, like expanded eligibility under Medicaid expansion, are at risk of losing their health care.
A February report by the Georgetown University Center for Children and Families, found that nationwide at least 6.7 million children are at risk of losing Medicaid coverage and becoming uninsured when the federal emergency declaration ends — and Missouri was one of the top states where children were especially at risk.
Poor administrative procedures was one factor that could contribute to the loss in coverage, and the report specifically highlighted Missouri’s use of LexisNexis to conduct address searches to verify eligibility.
After The Kansas City Star reported the system had erroneously flagged Missourians with out-of-state residents with the same name to cut off benefits, the Department of Social Services paused the practice.
Administrative hurdles have led to declines in coverage before. Between January 2018 and December 2019, roughly 100,000 children lost Medicaid coverage. Advocates pointed to barriers in the renewal process, such as a heavy reliance on paper forms and long call center holds, that contributed to the decline.
In February’s oversight committee meeting, Richardson said there are 1.2 million Missourians on Medicaid — and all but the recently enrolled will have to go through the redetermination process when the emergency declaration ends.
“Obviously,” Richardson said, “there’ll be a lot of work on the state’s part to sequence that and to get that done expeditiously.”