Aneka French applied for Medicaid in October, not long after Missouri became the 38th state to expand eligibility for the program.

But her application sat for months in a backlog with tens of thousands of others. While she waited, French, 45, an uninsured medical technician from St. Louis, paid out-of-pocket when she was treated at a health clinic for a knee injury last fall.

For nearly a decade, Missouri’s Republican political leaders resisted expanding eligibility for Medicaid, the state-federal health insurance program for people with low incomes. It took effect in summer 2021 after a voter ballot initiative passed in 2020. Now, Missouri has more pending applications for MO HealthNet — the name of the state’s Medicaid program — than people enrolled through the expansion. While 64,210 people have been approved as part of the expansion, nearly 73,000 applications were pending as of early February.

In the state’s most recent report, it said it was taking an average of 70 days to process typical applications — longer than the 45 days allowed by federal law.

“This means that in the midst of a raging pandemic, people who are finally able to get health coverage are being left out of the system and are left waiting and waiting,” said Melissa Burroughs, associate director for strategic partnerships at Families USA, a consumer advocacy group. “This is a complete injustice to those hit hard financially and healthwise by the pandemic.”

By contrast, most other states are processing Medicaid applications within a week, with many cases taking less than a day, according to federal data from 2021.

Kim Evans, director of the Missouri Department of Social Services’ Family Support Division, told the MO HealthNet Oversight Committee in February that the delay is due to a shortage of workers that has become more acute because of the pandemic. She also said the agency was stretched thin in the fall when it had to handle applications submitted during open enrollment in the Affordable Care Act’s marketplace, where people sign up for private coverage but can be redirected to Medicaid if they qualify.

Before expansion, Missouri’s Medicaid program did not cover adults without children. Now, Medicaid is available to all Missourians with incomes below 138% of the federal poverty level, or about $18,800 per year for an individual. Those whose applications are approved will be eligible for coverage retroactive to the month they applied, and possibly up to three months before then.

But Tricia Brooks, a research professor at Georgetown University’s Center for Children and Families, said people waiting to have their applications approved typically keep acting as if they are uninsured, delaying needed care and avoiding preventive services such as health screenings. If they do seek care, they will face large medical bills if their application is later denied.

French, the St. Louis medical technician, was notified in January — three months after she applied — that her Medicaid application had been approved. She said that if she had been approved sooner, she might have gone to an emergency room for her knee injury but didn’t because she was worried about getting stuck with a large bill. Instead, she went to a community health center that charges uninsured patients on a sliding fee scale based on their income.

Missouri is not the first state to experience such delays. When 26 states expanded Medicaid in 2014 under the ACA, many struggled to keep up with the demands of applications. For example, California in June 2014 had a backlog of 900,000 applications, prompting a lawsuit by health advocates.

Patient advocates say Missouri had years to get ready to expand Medicaid. And, they note, Missouri’s delays in processing applications have been an ongoing problem that worsened after expansion.

“At the very least, they are starved for resources, and, at worst, they are doing this on purpose,” Burroughs said.

Brooks said Missouri has consistently taken more than 45 days to process applications. She said that more than 40% of applications in 2018 needed more than 45 days to process and that the number rose above 50% in 2019 and to 60% in 2020.

“Where’s the accountability and federal oversight when there is this kind of historical evidence that Missouri’s eligibility enterprise is significantly out of compliance with federal standards?” Brooks asked. “The situation has worsened, not improved.”

Centers for Medicare & Medicaid Services spokesperson Beth Lynk said the agency is aware of the problem and is working with Missouri to bring it into compliance.

The delays in Missouri also stand out because of the state’s long resistance to expansion.

Even after the voters approved the ballot initiative in 2020, the Republican-controlled state legislature refused to fund the expansion, and the state withdrew its plan. In August, a judge ordered the state to start accepting applications from newly eligible adults. Missouri did not begin processing them until Oct. 1 because of a need for computer updates.

Oklahoma expanded Medicaid in much the same way as Missouri: Voters approved it in 2020, to begin July 1, 2021. But Oklahoma has been far quicker to enroll people in its expansion program — more than 230,000 had been enrolled through December 2021, nearly four times as many as Missouri had signed up through early February. Oklahoma gives people an answer as soon as they submit their application.

Washington University health economist Timothy McBride said the patchwork computer systems that Missouri’s Medicaid program uses are extremely outdated and have caused problems for years.

Adding to the challenge, Missouri is reviewing the eligibility of tens of thousands of applications submitted through the federal marketplace during open enrollment. But because the marketplace assesses eligibility, some states that expanded Medicaid recently, such as Virginia and Louisiana, use that federal determination to handle the increased volume of applications and get people enrolled more quickly.

Starting in September, Moshe Biron, 33, of suburban St. Louis called Missouri’s Medicaid help line at least 20 times, spending more than 15 hours on hold trying to figure out whether his five children still qualified for coverage after he started full-time work as a teacher. Through his state senator’s office, he learned in December that his children remained eligible but that he and his wife did not.

Department of Social Services spokesperson Heather Dolce said the Family Support Division was “aggressively tackling” the backlog by offering staffers overtime and prioritizing the oldest applications.

But health advocates criticized the agency for hiring third-party vendors to check the income and address information, which sometimes results in bad data that department staffers must fix. For example, some Medicaid recipients were erroneously flagged as living out of state, triggering a removal and appeals process. The state has paused residency checks at least through February.

Brooks said Missouri’s application processing time could get even worse when the covid public health emergency ends — now slated for mid-April. Federal rules in place during the pandemic have prohibited states from removing Medicaid recipients who are no longer eligible due to income status since March 2020.

But the state will soon have to review every enrollee’s eligibility status, adding thousands of cases to the workload. In December, Missouri had nearly 1.2 million Medicaid enrollees, up from about 861,000 in March 2020.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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