Missouri’s Medicaid program expected to see an uptick in enrollment with the rollout of HealthCare.gov because outreach efforts would attract more people – particularly children – who were already eligible.
Indeed, the federally run marketplace has turned over to the Missouri Department of Social Services more than 25,000 applications from people who seemed to meet the state’s income criteria.
But the state hasn’t added any of them to the Medicaid rolls.
Rather, the number of Missourians on Medicaid has actually decreased by about 14,000 since the marketplace launched on Oct. 1.
The state says application data forwarded by the online exchange is fraught with errors and duplication. “We’re in the process of sorting it out,” said Brian Kinkade, acting director of the social services department.
As for declining Medicaid enrollment, Kinkade and other experts chalk that up to the improving economy, though some say startup problems with the state’s transition to online applications also may be a factor.
“I think it’s going to take some time to get all the kinks worked out,” said Ryan Barker, a vice president at the St. Louis-based Missouri Foundation for Health, a nonprofit that works to reduce the number of uninsured in the state.
The online marketplace was intended to be a one-stop shop for consumers, where they could enroll in a subsidized private plan or, if they met income guidelines, have their application automatically sent to their state for Medicaid coverage.
Missouri wasn’t expecting a huge surge in Medicaid rolls. Despite a push from Gov. Jay Nixon, the Legislature has rejected expanding the program to cover everyone making less than 138 percent of the federal poverty level, or about $15,800 for an individual.
That leaves Missouri with relatively low income thresholds for most groups – for example, parents can make no more than 19 percent of the poverty level. For a single mother with two children, that means an income limit of $3,711 a year. Childless adults aren’t covered unless they are elderly or disabled.
However, Missouri’s threshold for children is one of the most generous in the nation – three times the poverty level, or $70,650 for a family of four. Families in the upper income tier must pay premiums. Even so, additional children were expected to sign up once their parents checked out the marketplace.
The idea that Medicaid would grow, even in states that rejected expansion, was known as “the woodwork effect,” based on the theory that uninsured people who were already eligible would come out of the woodwork.
But in addition to the front-end technical glitches that consumers found with HealthCare.gov, the website has had trouble sending accurate information to states.
“Getting the systems well-synchronized is a technological challenge,” said Sidney Watson, a St. Louis University law professor who specializes in health care. She said that unlike some states, Missouri chose to make its own Medicaid determinations rather than let the federal marketplace decide whether applicants meet income criteria. Making the two Web portals work together seamlessly could take time, she said.
“I don’t think the sky is falling when it’s not working the first month,” she said. “I do think the best fix would be if we let the marketplace do the determination” of eligibility.
Kinkade said Missouri received “a flat file, basically like a spreadsheet. It’s not in a format that can be automatically used. We’re finding that the data’s not of the best quality. There’s a lot of duplications, a lot of missing information, a lot of poor-quality information.”
The federal website doesn’t screen applicants to see whether they are already receiving Medicaid, said Emily Rowe, a unit manager in the state’s Family Support Division.
“What we’re finding is, the children are already covered. The parents are still over the income” limit of 19 percent of poverty.
Thus, while the federal Centers for Medicaid and Medicare Services says the marketplace found 25,487 Missourians eligible for Medicaid, none has been added.
“In time there may well be some kids” added to the rolls, Kinkade told the MoHealthNet Oversight Committee on Monday. “Right now there’s too much noise … to really tease that out.”
The oversight committee, which is composed of legislators and health care professionals, interpreted another report – the state’s declining Medicaid enrollment – as good news.
In the last three months of 2013, the state’s Medicaid caseload dropped by about 14,000 people – including 7,829 children.
Committee Chairman Tim McBride, a health economist at Washington University, said Medicaid enrollment tracks the economy, particularly the state’s unemployment rate. Thus, Medicaid enrollment rose during the Great Recession.
“If you look at unemployment, Missouri was stuck at 10 percent until the end of 2010, then it started dropping,” McBride said. “You can see that coinciding with the slow drop in (Medicaid) enrollment.”
Committee member Joe Pierle, of the Missouri Primary Care Association, said he hopes that parents are finding jobs with private insurance that covers their children.
Without expanded Medicaid eligibility, Pierle noted, Missouri leaves most people making less than 100 percent of poverty in a coverage gap.
“They’re working, they make too much to qualify for Medicaid, they make too little to qualify for subsidies in the exchange,” he said. “There are no doors open for the poorest of our citizens.”
At the same time that state workers must sort out the marketplace data, the Family Support Division is shedding jobs as part of a move to online applications. A backlog of applications has resulted, and the state is paying workers overtime to catch up.
Applications are considered overdue if they take longer than 30 days for parents and children. The timeline is shorter for pregnant women and longer for the elderly and disabled.
“We have been working aggressively to get that caught up,” said Alyson Campbell, director of the Family Support Division.
In one improvement that kicked in last month, workers don’t have to key in the information from Medicaid applications filed online. The data now flows automatically to the “worker portal,” she said.
“It’s a new system, and there’s always issues we need to address, but the staff reaction has been extremely positive,” Campbell said. “They’re finding it to be easy to navigate.”