Testimony: Trends in Medicaid Enrollment, Causes of Those Trends, and Suffering Created in Missouri Households by Loss of Medicaid

Below is an unedited version of the Testimony submitted by Empower Missouri’s Executive Director at a hearing regarding the hundreds of thousands of Missourians dropped from the Medicaid rolls. Find a live Twitter thread of the hearing here.

September 11, 2019

To:       Members of the General Assembly
From:  Jeanette Mott Oxford, Executive Director – Empower Missouri

In August of 2013, Alyson Campbell, then Division Director of the Family Support Division (FSD), came to visit me to explain that FSD was going to have to reorganize in order to have “a modern business plan.” I immediately feared for the clients because I have closely followed public policy around poverty issues in Missouri since 1991, and I had seen previous years in which changes were made in how programs were administered. There were always glitches, inappropriate loss of benefits for some, and confusion for both FSD workers and clients. However, from where I sit, the period 2013-2019 has been the most tumultuous, painful and harmful of the years in which I have been observing the inner workings of FSD.

Here are some of the problems that we have noted:

  • Long waits at call centers (20-30 minutes reported at first; 45 minutes recently), many dropped or “deflected” calls.
  • Lost applications or documentation of income, ID’s, etc.
  • Paperwork sent to old addresses.
  • Failure to check eligibility in SNAP/TANF databases.
  • For several months after its implementation, the Medicaid renewal system did not have access to recipients’ federal tax income information. The system was not programmed to include a necessary field where client gave consent, an inexcusable oversight.

The IT issues named above our exacerbated by ongoing ineptitude around getting the FSD computer systems to network properly. Presently the systems are:

  • FAMIS  (pronounced ‘famous’) is COBOL-based, brought on-line in the mid 1990’s as a transitional system. 
  • MEDES  (med-ez), officially the Missouri Eligibility Determination and Enrollment System.  First rolled-out – in small part – in 2013, the state has used a variety of software providers, by contract, to make incremental switches from FAMIS to MEDES.  Kids on Medicaid are now on MEDES.  Most adults are too.
  • My DSS is the web-based system to apply for benefits. There is a digital divide, and those in poverty have much less access to the web. It takes a long time to complete an application, and My DSS is not smart phone friendly. My DSS is not compatible with FAMIS or MEDES. State workers manually re-enter data, and this is highly inefficient and also leads to mistakes in data entered.
  • The unnamed administrative functions system. It is somewhat compatible with FAMIS and MEDES. It incorrectly reported SNAP data to federal government officials, causing Missouri to be sanctioned.

The result of these many problems is a steep decline in persons enrolled in Medicaid in Missouri, and this is especially true for children’s cases. Missouri is among the bottom 10 states, ones that automatically renew less than a quarter of Medicaid recipients (source: Henry J. Kaiser Family Foundation). Ten states are able to automatically renew over 75 percent of recipients.

In this era of term-limits, it is easy to miss patterns from previous years. To point out how some issues and excuses are being recycled, I have attached:

  • Materials here from a Jobs with Justice Workers’ Rights Board hearing in March 2014; and
  • Letters that we sent to Campbell and then Department of Social Services (DSS) Director Brian Kinkaid in 2013, expressing our concerns about FSD reorganizations and ways that families could be harmed.

These detail that Missouri was the only state to show a decline in food stamp recipients from December 2008 to December 2013, while the national average was a 47% increase. Enrollment in Medicaid had declined by 50,000, and in December 2013, we were one of only two states with an increase in the number of uninsured children according to a report from Tara Mancini and Joan Alker at Georgetown University Health Policy Institute (as detailed in the letter dated December 31, 2013). Administrators in the department at that time cited improvements in the economy as the reason for these declines, despite ample evidence to the contrary.

It was a terrible mistake to stop have face-to-face meetings with caseworkers in local county offices. It may be “a modern business plan” to do so, asking families living in the desperation of poverty to go through the kinds of experiences that many of us encounter with our phone company or health insurance provider. However, the stakes are very high for these families. They do not live in the same comfort that Missourians with middle and upper incomes live, and they have barriers and challenges that most of us cannot imagine, having not gone through their trials. That is one reason we have asked legislators to participate in the 2019 Missouri SNAP Challenge (and details are in your Inbox if you have not yet read our September 9 letter).

Far too many members of our General Assembly have said a statement very like this one to me: “If people are really needy, they will find a way to make the new web and call centered system work for them.” This intentional indifference ignores the realities of life that many endure.

Only by building relationships of trust will families in poverty share information that can lead to better outcomes for children. A web and call center-based system is cruel to families in poverty. Those who experience evictions, utility shut offs, life without working stoves and refrigerators, lack of transportation, lack of access to computers and broadband need a well-trained professional to be available to them in an office that they can reach on foot or by begging a ride from a friend.

I suggest this analogy for thinking about what Missouri has done to its Medicaid system. It is like a game of musical chairs in which the losers are blamed for not trying hard enough. Governor after governor has reduced the number of employees at DSS because we have an outdated, unfair, and inadequate revenue system. They have claimed, “we will work smarter” and with less people. Those governors have submitted budgets that invested too little in staffing and in technology, and the General Assembly (which has cut more than $2 billion in taxes, leaving our state $3.9 billion below the Hancock revenue caps) has passed those budgets because there was “no money” for adequate staffing and technology.

Chair after chair has been taken away, and “losers” have fallen out of various public assistance programs, safety net policies that are there to protect us all in times of unemployment, sickness, natural disaster, and other challenges. Some see the decline and assume it is good news, but Empower Missouri always asks to see the outcomes of policies that relate to health and well-being. Are more people homeless or dependent on food pantries? Are children successful in school? What are our infant mortality rates? What are trends in mental illness? Etc.

We can blame those who do not get that final chair in a game of musical chairs. We can say “You did not listen carefully enough for the music to end. You did not run fast enough. You should have tried harder.” But the truth is that we have created a game in which there are not enough chairs. The trust is that some of us limp toward a chair with a cane or roll toward it in a wheelchair while others sprint on legs heavy with muscles.

A compassionate response, creating a system that actually provides needed supports to households without access to basic human needs, actually will do the most to improve the quality of life for all of us in the end. All of us have repercussions in our lives when some go without in our society, but certainly those who suffer the most are those living without food, shelter and health care that is needed themselves. Let us do the right thing for our neighbors and insist that our broken FSD system be mended immediately.

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