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Two Way: The Next Steps In Missouri's Medicaid Expansion

This picture depicts an application for presumptive eligibility, produced by the Missouri Department of Social Services.
Sebastián Martínez Valdivia
Filing an application for presumptive eligibility is the starting point in applying for Medicaid coverage.

Missouri is in the process of implementing Medicaid expansion. A judge earlier this month ordered the state not to deny applications from people who would qualify under the expanded eligibility. Now the state says it’s working on being able to process those applications. Patricia Boozang, a senior managing director at the consultancy Manatt Health, has advised states on designing Medicaid programs, and spoke with the Health & Wealth Desk about Missouri's fraught expansion.


Health & Wealth: So now that the state is finally expanding Medicaid, what are some of the obstacles people who are newly eligible might face in getting coverage?

Patricia Boozang: I think one thing that’s really important and we see it all over the country is there are a lot of people who are eligible for Medicaid and not enrolled. And I think that’s been a particular challenge in states that are expanding Medicaid late, if you will, or sort of latecomers to expansion, because you have a lot of people that think like, “Ugh, i’ve been there i’ve tried that, I’ve applied before, I’m not eligible.” Especially with the delay and I think some of the volatility and the dynamic around Missouri’s expansion, the market is probably pretty confused about are we expanding or aren’t we expanding and when. And I think that could really well get in the way of people applying as well. You know they might just be assuming — unless they’re following this very closely — they might just have heard, "Yep see we’re not really going to expand."

So I think that’s going to be one of the biggest issues in Missouri. Medicaid applications are not simple, although the [Affordable Care Act] has gone a long way to streamlining that application and to streamlining the requirements and requiring the states to do data-matching. Some states do it more effectively than others, so whether Missouri has good data-matching agreements with other agencies in the state, whether they really rely on that data or whether they in some instances rely on the consumer, the applicant attesting to some information rather than requiring documentation — all of those myriad decisions could make the process easier or harder for applicants.

H&W: One of the concerns opponents of Medicaid expansion in the legislature raised was long-term sustainability. You’ve worked on Medicaid sustainability, what do you make of that concern?

PB: I think the first thing to keep in mind is that there are a number of sort of medicaid specific offsets and savings that come with expanding. We think about the cost of adding these new people ... but there are state savings from transitioning to Medicaid expansion. Whether that’s currently eligible populations that are pregnant women, for instance, or certain people who today would seek a disability determination but with expansion they know they can get their health coverage in the expansion group and the state’s going to get a higher federal match for that group.

There’s a sort of whole laundry list of ways in which the state transitioning their gateway to health enrollees to this new expansion group for which they were also getting the enhanced federal match, so that’s the first piece of it. All states have seen savings and increased revenue related to implementation of expansion that offsets for some period of time all costs of expansion and over time obviously the expansion does start to cost as the state absorbs those savings.

I think it’s a little bit of a red herring to say that this is just a coster that states can’t afford. And I do think that there are a number of states that even beyond the financial debits and credits of expansion, are making tremendous strides in making their medicaid programs more sustainable.

H&W: There has been significant ideological opposition to Medicaid expansion, as we saw with the legislature’s decision not to fund it as the governor asked — have we seen that kind of opposition in other states that have expanded Medicaid?

PB: So to answer the first part of your question, yes we’ve certainly seen real obstacles to expansion in other states. Maine has a somewhat similar approach or set of circumstances to Missouri in that they also expanded by ballot initiative and the governor really declined to implement, if you will. So that’s sort of one clear analogy. I think in other states, you know, expansion is passed by ballot initiative and then the legislature has made decisions to limit expansion. Now in Missouri’s case the ballot question limits the legislature’s ability to do that, limits the ability to say okay we can expand but you’re going to have to impose significant cost-sharing on the expansion population or other kind of limiting factors.

So yes it’s been seen in other states but I do generally think Medicaid agencies are implementers and their mission is to provide coverage. And when they have a law in the state or a direction from the governor otherwise or legislature to implement expansion, I think genuinely you’ll see them making good-faith efforts to do that and to get eligible people enrolled.

Sebastián Martínez Valdivia was a health reporter at KBIA and is documentary filmmaker who focuses on access to care in rural and immigrant communities. A native Spanish speaker and lifelong Missouri resident, Sebastián is interested in the often overlooked and under-covered world of immigrant life in the rural midwest. He has a bachelor's degree in broadcast journalism from the University of Missouri and a master's degree in documentary journalism at the same institution. Aside from public health, his other interests include conservation, climate change and ecology.