Medicaid’s big paperwork problem
After a federal rule expired this spring, millions of people have been disenrolled from Medicaid. Many of them may still be eligible.
Over the past several months, Dr. Teresa R. Blaskovich, a pediatrician in Billings, Montana, has seen an increase in the number of children missing their appointments. Many of them, she said, have recently lost their Medicaid coverage, joining the 8.8 million people across the country who have been disenrolled since April.
“All of a sudden I was noticing that instead of saying Medicaid, it was saying self-pay,” Blaskovich said. “And then what we have seen is that those families are starting to not come to their next appointment if they have an outstanding bill.”
Medicaid is a federal program that provides health insurance to 85 million people, including children and seniors and people who are pregnant, disabled or have low incomes. During the pandemic, the federal government mandated that states maintain continuous Medicaid coverage for their residents. But that rule expired in March, prompting states to redetermine the eligibility of Medicaid recipients for the first time in three years.
By the time this “unwinding” is completed next spring, the Urban Institute estimates that 18 million people will have lost Medicaid coverage, with 3.8 million of them becoming completely uninsured. The consequences could be far-reaching, as many studies show that uninsured people are less likely to seek out preventative care and have higher mortality rates. They’re also far more likely to accrue significant medical debt.
In Montana, where Blaskovich practices, 60% of the state’s Medicaid recipients — including 24,000 children — have already been disenrolled. Blaskovich said this loss of coverage means that patients aren’t being diagnosed with developmental delays or treated for chronic conditions. It’s also kept them from receiving vaccinations and a potentially life-saving RSV-prevention drug, which is usually available only to infants under 8 months old.
“All of a sudden I was noticing that instead of saying Medicaid, it was saying self-pay.”
Of the 12 U.S. states with the highest disenrollment rates, half are in the West: Idaho, Montana, Alaska, Utah, Nevada and Colorado. Some of the disparities in disenrollment rates are due to when and how states started reviewing cases. But Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, said the rest of the disparity can be attributed to states’ administrative decisions.
That’s especially true when it comes to “procedural disenrollments,” which can occur when Medicaid recipients fail to update their address or complete renewal packets. Nationwide, KFF, a nonprofit focused on health issues, reports that 72% of disenrollments have been procedural.
Wagner, who believes many of these people are still eligible for Medicaid, said confusing mailings and administrative backlogs are to blame. She has spoken to people who mailed in their renewals but were disenrolled anyway, because their forms were never processed. Others, who were trying to clear up their eligibility, found themselves stymied by long call-center wait times.
Dr. Lauren Wilson, a pediatrician in Missoula, Montana, recently saw a patient who’d spent more than four hours on hold with the state’s Medicaid office. “That’s a really stressful thing to be doing when you’re in the hospital and you have just given birth,” said Wilson, who is president of the Montana Chapter of the American Academy of Pediatrics.
Last week, Wilson’s organization wrote an op-ed urging Montana to pause procedural disenrollments — something that many states have been forced to do — so that Medicaid administrators can catch up on paperwork, saying: “People shouldn’t lose their health insurance coverage because the state is short-staffed.” (Montana’s Department of Public Health and Human Services did not reply to a request for comment.)
Wagner also wants more states to prioritize “ex parte renewals,” which are automatic and based on electronic income information. “That keeps people who are clearly eligible on the program, and it frees up eligibility-worker time to deal with the more complicated cases — to hopefully answer the phone and process paperwork,” Wagner said.
Though all states are required to perform such renewals, some are better at it than others. Montana and Idaho, for example, have some of the lowest rates of ex parte renewals in the country. They also have the second- and third-highest disenrollment rates. Arizona, on the other hand, has a high ex parte renewal rate and a low disenrollment rate.
“People shouldn’t lose their health insurance coverage because the state is short-staffed.”
Increasing efficiency would help those who are no longer eligible for Medicaid, too. Many could likely get coverage from, say, the Children’s Health Insurance Program, or a heavily subsidized Marketplace plan. The problem is that many people don’t know how to obtain such coverage — and are unable to get the help they need. “Even though the eligibility is there,” Wagner said, “the administrative barriers of navigating it tend to be big obstacles.”
Wagner was quick to point out that these are not new problems. Medicaid recipients have always lost coverage at redetermination time. It’s just that, this year, the availability of data and the volume of disenrollments drew national attention.
“There’s kind of a pivotal moment where we can decide, do we accept this?” Wagner asked. “Do we accept that this many eligible people lose coverage, that people have to wait hours in order to talk to an eligibility worker? Or do we declare that this is not acceptable, and that we have to fix the system for the long run?”
Susan Shain reports for High Country News through The New York Times’s Headway Initiative, which is funded through grants from the Ford Foundation, the William and Flora Hewlett Foundation and the Stavros Niarchos Foundation (SNF), with Rockefeller Philanthropy Advisors serving as fiscal sponsor. All editorial decisions are made independently. She was a member of the 2022-23 New York Times Fellowship class and reports from Montana.
