‘Not out of the woods yet’: Missouri finally expanded Medicaid, but hard work remains

Three months after Medicaid expansion was first slated to go into effect, newly eligible individuals will finally begin to enroll in coverage.

For Missourians who lack health insurance under Missouri’s Medicaid system, and for the advocates who help them sign up, Friday has been a long time coming.

“It’s a relief,” said Earlene Bolton, the outreach coordinator for Legal Services of Eastern Missouri’s Connecting Kids to Coverage program.

“We’ve been working on this issue for so many years and knowing how much it was needed, and just to be at that point, it’s like, ‘Oh, my god. I can get people into this coverage. I don’t have to have households that I’m working with that have gaps in the care that they’re able to receive.’”

Initially scheduled to go into effect July 1, voter-approved Medicaid expansion faced hurdles in the legislature and later the courts.

After the Missouri Supreme Court ruled Medicaid expansion must go into effect and a Cole County judge affirmed in early August that eligible residents must be permitted to enroll, the Department of Social Services said it would still take nearly two months until Oct. 1 for necessary system updates to make that happen.

In the weeks since, advocates and healthcare providers have worked to let eligible residents know that Medicaid expansion is now an option and have tried to cut through the confusion back-and-forth rulings pinging through the courts may have wrought.

At the Social Welfare Board, a clinic that provides healthcare at low cost to uninsured residents in St. Joseph, roughly 60 percent of the clinic’s patients are estimated to qualify, said Linda Judah, the clinic’s executive director. Prior to expansion going into effect, that number was closer to 10 percent.

“We overcame one hurdle at a time in order to get Medicaid expanded. But we’re not out of the woods yet,” Judah said. “There’s still resistance out there, for whatever reason.”

Advocates have set up hotlines to answer residents’ questions, held in-person clinics to help people apply and attorneys who sued to force the state to expand Medicaid are keeping an eye out to ensure the state acts on its word.

“We expect this switch to flip on on the 1st and people to be enrolled and have their claims processed and approved,” said attorney Chuck Hatfield, who represented plaintiffs that sued the state. “We’ll be looking to see if that works.”

‘A blessing’

Amanda Reynolds, a St. Louis resident who has health issues from chemotherapy she endured to treat cancer as a child, has been unable to work and left without health insurance. Despite feeling a mass in her stomach for years, she’s been unable to get the necessary scans without health care coverage.

“Had I had access to uninterrupted health insurance, I would be working, functioning, and living a life that many take for granted,” Reynolds said in a statement Friday. “Today’s milestone for Medicaid expansion implementation gives me the hope I haven’t had for as long as I can remember. I’m ready to turn the page in my healthcare battles.”

Jon Roberts, a doctor who helped found the Good Samaritan Care Clinic, a free health clinic in Mountain View in southern Missouri, hopes Medicaid expansion will be able to help fill the gap the clinic will leave behind.

After operating for 18 years, a confluence of the “the perfect storm” brought on by the pandemic has led the clinic to make the difficult decision to shut its doors come November.

“We’d rather quit while we’re ahead,” Roberts said. “And we’re estimating about 70% of our patients will be eligible for the expansion of Medicaid. So that’s a blessing.”

At the end of each office visit, clinic staff have been explaining to patients how to apply for Medicaid expansion and leaving them with three months of medication to help keep them afloat in the interim, Roberts said.

At the Social Welfare Board, each patient is referred to a patient advocate who works for the local hospital system to help them sign up.

“It has been confusing for the patient. It’s actually been confusing for providers and professional staff as well,” Judah said. “But at the end of the day, we just try to stay up with what is going on with the state legislature and doing what we can to educate folks accordingly.”

On the same day enrollment is slated to begin, Bolton and Geoff Oliver, the program director for Legal Services of Eastern Missouri’s Connecting Kids to Coverage program, were working to set up a free clinic in St. Louis to help residents apply.

It’s their second clinic they’ve held so far, with more on the way. Bolton said questions have ranged from whether applicants’ providers and medications will be covered to a large demand for dental care.

“We’ve just been doing a lot of that coalition building, relationship building to make sure we get the word out,” Bolton said. “Because it is new. It’s a big population — that 270,000 people who never were eligible for anything comprehensive.”

Department work

With the build-up that has led to enrollment for the approximately 275,000 eligible Missourians, it now remains to see if the system works.

Following the Cole County judge’s August ruling, Department of Social Services officials said that while newly eligible individuals could begin to apply, applications would not be processed and individuals would not be enrolled until Oct. 1 due to necessary system updates and securing additional personnel.

“It will cause some people to have delayed receiving care in the meantime,” Oliver said of the wait. “And that’s unfortunate.”

It’s a delay that caused attorneys who sued the state to argue in an August letter that the department was not only violating the court order, but also federal law.

In a response to the attorneys’ letter sent Aug. 31 and provided to The Independent, John Sauer, Missouri’s solicitor general, defended the state’s Oct. 1 enrollment date as “a good faith estimate” of the time it would take to complete system upgrades.

The Missouri Eligibility Determination and Enrollment System is what is used to determine eligibility for Medicaid programs. Since the court ruled that no greater restrictions or additional burdens be placed on the expansion population, the system must also be used to process the expansion group in the same manner, Sauer argued.

Once coding, testing and staff training were completed any pending applications would be processed as a “batch file” to determine eligibility which would trigger letters to be printed to inform applicants of their status and coverage. It would also move eligible individuals into the system where providers can see if they qualify.

The system should also show the updated status of applications on Oct. 1, Sauer wrote. At the time, the state was still on track to fully implement the new system by Oct. 1, or earlier if possible, Sauer wrote, but stressed that if delays occurred it would affect all Medicaid and public benefit programs.

A spokeswoman for DSS did not respond to questions sent Wednesday. A spokeswoman told St. Louis Public Radio that a state plan amendment was submitted to federal regulators last week.

The department has previously said it was working to verify information on applications it has received to expedite their processing come Oct. 1. In addition, it will explore offering coverage retroactively to July 1 for applications received before Nov. 1.

In response to requests for communications documenting department decisions and copies of contracts, Sharie Hahn, DSS’ general counsel, declined to provide attorneys documents through an open records request under the Sunshine Law.

“Because this matter is in litigation, the proper channel to obtain records is through the court process, where the rules of discovery apply,” Hahn wrote in an Aug. 31 letter, adding that the department would be authorized to close the requested records because of litigation.

Hatfield said Wednesday that at this time plaintiffs don’t intend to head back to court.

“We’re going to see what happens here over the next few days,” he said.

Oliver said he will be waiting to see if clients who have already applied receive eligibility determinations, get notices informing them and what they contain. He expects notices to arrive early next week.

In the meantime, the work to help eligible residents apply continues.

“We’ll be very busy, but it’s a good busy,” Bolton said, “because we’re getting help for so many people — that for years we have seen fall between the cracks with making sure that their healthcare needs are met.”