Burdensome state eligibility redetermination processes have pushed down Medicaid enrollment in a number of states, raising questions about whether eligible adults and children are being wrongly dropped from coverage, according to a new report.
Enrollment in Medicaid and the Children's Health Insurance Program dipped last year by about 1.6 million, including 744,000 children, according to the report by the liberal advocacy group Families USA.
It fell most sharply in states like Tennessee, Arkansas and Missouri, which have established tougher new eligibility redetermination processes. Those three states saw declines of 9.7%, 7.3% and 7.2%, respectively.
Tennessee began making manual eligibility redeterminations using a mailed 98-page packet in 2016, after the botched rollout of a new redetermination system. Arkansas gives some beneficiaries only 10 days to respond to additional requests for information. Missouri launched a new automated system last year that no longer uses data from other state safety-net programs to verify people's eligibility.
Other states with relatively large Medicaid and CHIP enrollment drops were Illinois, Wyoming, Ohio, Massachusetts and Utah.
Some elected officials in these states tout a strong economy as the reason for the shrinkage in Medicaid rolls, and have welcomed the reduced state spending on the program.
Nationally, political debate and litigation has centered on Medicaid enrollment reductions driven by new Medicaid work requirements established by the Trump administration and Republican elected officials in a number of states.
There also is concern about enrollment losses and uncompensated care related to state waivers eliminating 90-day retrospective Medicaid eligibility. Critics say that's another administrative barrier the administration and the states have erected to make Medicaid harder to access..
The Families USA report suggests that onerous eligibility redetermination processes are at least as big a threat to poor people's coverage as those other measures. The redetermination processes may violate federal rules requiring state Medicaid agencies to use all available data to renew a beneficiary's eligibility before requesting any additional information from the person.
"States with the largest drops in Medicaid and CHIP enrollment had … flawed eligibility redetermination processes that put undue burden on beneficiaries to verify their eligibility," the report said. "The failure of some states to correctly implement the law—and the failure of the Trump administration to effectively enforce the law—is driving a drop in Medicaid and CHIP enrollment that shows no sign of slowing down."
Eliot Fishman, Families USA's senior director of health policy, said Arkansas' Medicaid rolls dropped far more last year because of eligibility redetermination than because of its work requirement, which disenrolled 18,000 people before a federal judge blocked it last month.
"Both are major threats but the churn issue has not gotten the attention commensurate with the size off the threat," he said.
State Medicaid agencies in Tennessee and Arkansas did not respond to requests for comment by deadline. The Missouri Department of Social Services said the state's significant Medicaid enrollment decline is due to an improving economy, the repeal of the Affordable Care Act's individual mandate, and new technology enabling the state to better track eligibility annually.
Experts doubt the enrollment drops are mainly due to a stronger economy. Timothy McBride, a Washington University health economist who chairs the oversight committee for the Missouri Medicaid program, said employment gains couldn't account for 67,000 children losing coverage over the past year.
That's because a Missouri family's income level would have to rise from 100% of the federal poverty level to 310% for a child to become ineligible for CHIP coverage. "I'm having a hard time believing that's happening," he said.
It's far more likely, he argued, that the enrollment decline is driven by the state Medicaid program's "notoriously bad" computer system and a troubled call center system that puts people on hold for an hour and then cuts them off.
Meanwhile, Missouri's Republican-led Legislature, which currently is developing the state budget, is welcoming projected Medicaid savings of nearly $200 million a year due to the 85,000-person enrollment decline over the past year.
In Tennessee, where Medicaid and CHIP enrollment dropped last year by nearly 149,000, including 55,000 children, advocates say some beneficiaries have repeatedly mailed in their lengthy renewal application, only to be dropped from coverage when the state said it never received the packet.
The head of the state Medicaid program recently told lawmakers that out of 218,000 Tennesseans who have appealed an eligibility denial since 2015, 159,000 people subsequently have been found eligible.
"Tennessee has created as much red tape as possible to see if families can run the gantlet," said Michele Johnson, executive director of the Tennessee Justice Center. "But if you lose that many kids from coverage, someone should be raising a red flag and saying, 'How can we fix that?' "