The improving economy alone cannot account for 2018's substantial decreases to the number of people enrolled in MO HealthNet, according to watchdog organizations and some Missouri lawmakers.
MO HealthNet, Missouri's Medicaid program, provides health care and support for more than 950,000 people. However, in 2018, according to a report from Families USA, the number declined by 69,045. Of those, more than 55,000 were children, the report stated. The Children's Health Insurance Program (CHIP) is the Medicaid program providing children's health insurance within MO HealthNet.
Families USA is dedicated to improving health care and access to health care for Americans, according to its website.
Data it collected show that of all the states and the District of Columbia, the percentage in Missouri's drop in Medicaid coverage (7.2 percent) was only exceeded by two states, Tennessee, which dropped by 148,596 enrollees (9.7 percent), and Arkansas, which dropped by 65,745 enrollees (7.3 percent).
Many states had much greater numbers of enrollees who fell off the rolls - California had a 274,120-member decline, but that was only 2.3 percent of enrollees for the state, which has more than 11.8 million enrollees in Medicaid. Louisiana, which has more than 1.4 million enrollees, had a decline of 6,456 (0.4 percent).
Kansas, with about 390,000 enrollees, saw a decline of only 94 members.
The changes in Medicaid enrollment cannot be explained by changes in underlying economy, the Families USA report said.
The drop in Medicaid enrollment varied greatly from state to state, according to the report. That is a strong indicator it was the states' policies that drove the declines, it noted.
Policy decisions that may have a punitive effect, including the states' monthly or annual redetermination processes, can account for greater losses of enrollees.
The three states with the largest percentage drops in coverage of Medicaid and CHIP (Missouri had the third-highest drop) all had challenges to redetermination for beneficiaries - including the inability to create online accounts to provide additional required information. They had to do so by phone or through mail.
Although Missouri has an automated Medicaid renewal process, in verifying beneficiaries' eligibility, the state's system did not use data from some programs, such as SNAP or Temporary Assistance for Needy Families, the Families USA report said.
The report concludes the oversight violates a federal regulation requiring use of that data. The report is also critical of Missouri's methods for redetermination, specifically a lack of automation and the reliance on physical letters in the process. The state sent letters asking enrollees to provide additional documentation, and if the enrollees didn't respond within 10 days, they were dropped.
In February and March, state Sen. Scott Sifton, D-Affton (St. Louis County); and state Rep. Crystal Quade, D-Springfield, sent letters to the Missouri Department of Social Services, expressing concerns about the state's process for redetermination.
Sifton inquired about the number of enrollees who were sent the letters. Patrick Luebbering, director of Family Support Division of Social Services, responded to Sifton's inquiries.
Luebbering said the state mailed out 102,550 annual renewals to recipients, and he pointed out that each of the mailings represented a "case," which could have included multiple household members. Of the people dropped from the MO HealthNet rolls, 43,200 failed to return the requested information.
More than 20,000 letters were returned because they were undeliverable.
However, the state had attempted to notify mail recipients in advance through the use of postcards, robocalls and text messages. Messages said enrollees would soon be receiving time-sensitive information.
Data from 2018 show 82,425 individuals lost coverage because of excessive income, according to Luebbering's response to Sifton. However, some of those enrollees may have moved to Medicaid categories that require premiums.
Even enrollees who return their responses late have opportunities to be redetermined, Luebbering said. If they return the renewal within 30 days of closing, their eligibility is reinstated. If they return it 30-90 days, the case will have been closed, but they'll be treated as a new application.
Sifton said there had been criticism leveled at the call center that handles telephone redeterminations.
"In the call center designated for family Medicaid information requests and renewals, the abandonment rate was 47 percent and the average wait time over the last quarter of 2018 was 28 minutes, 43 seconds," the response said. "(Family Support Division) did see a higher than average wait time in January 2019 of 42 minutes, and attributes this to weather, holidays, and the partial federal government shutdown."
Luebbering shared a chart with Sifton that showed 4,230 people appealed their removal in 2018. Of those, 2,047 had their cases reversed. While 1,882 appeals were rejected, and 301 were unresolved pending hearing decisions.
Among other things, Quade asked Social Services how long it takes for the appeals to be resolved. Luebbering also responded to her requests. Appeals took - on average - 42 days to be resolved.
The long waits - both on the phone and for resolutions to appeals - are unacceptable, Sifton said.
For instance, if the average wait time on the phone is 28 minutes, that means half of the callers are likely waiting much longer.
"The other thing that's clear from the responses that were given is that the notion of a drop in the unemployment rate is the reason for Missouri to be (about) the highest rate for drops," he said.
Sifton said it seems clear the drop in the rolls was intentional. If people aren't eligible for Medicaid, they shouldn't be in the program, he agreed, but said he's concerned many were dropped who remained eligible.
"The notion that this is because of the economy is clearly not the issue," Sifton said. "I'm concerned that people who were eligible were removed."
Also, Republicans have made a concerted effort to remove all people of working age from MO HealthNet rolls, he added. Late Tuesday night into early Wednesday morning, Democrats in the Senate rejected Senate Bill 76, which would have essentially removed all people 19-94 from the program by implementing work requirements, he said.