This blog is part of our Working Better Together series and was authored by Joel Ferber, Director of Advocacy at Legal Services of Eastern Missouri. This blog series is intended to provide our Health Law Partners with a platform to highlight successes, challenges, and innovative approaches to furthering health access and health equity in the states where they work.
The Long Road to Medicaid Expansion in Missouri
As anyone reading this blog knows, the adult Medicaid expansion was one of the centerpieces of the Affordable Care Act (ACA) and perhaps the seminal provision for clients of legal services programs. When the Supreme Court upheld the ACA in NFIB v. Sebelius, it found Medicaid expansion “voluntary” for the states, meaning that each state could choose whether or not to implement expansion. Before August 2020, Missouri was one of fourteen states that had not implemented the expansion, despite significant efforts by advocates, providers, foundations, and policymakers. In August 2020, Missouri voters approved a statewide referendum to expand Medicaid under the state constitution after years of legislative inaction. As a result, an estimated 275,00 more low-income Missourians would become eligible for health care coverage through Medicaid.
The Case to Enforce Medicaid Expansion
In May 2021, however, the Missouri Department of Social Services refused to implement Medicaid expansion, claiming that the state legislature had not authorized the necessary funding. In response to this violation of the state constitution, Legal Services of Eastern Missouri (LSEM), along with law firm partners Stinson LLP and Husch Blackwell LLP, filed a lawsuit (Doyle v. Tidball) on behalf of three low-income women who met the eligibility criteria for the new Medicaid expansion, but were denied coverage. In support, the National Health Law Program (NHeLP) filed an amicus brief on behalf of a diverse range of experts, including disease-based organizations, academicians, and health policy experts, showing the significant health impact of expansion and the devastating consequences of a failure to implement Missouri’s constitutional requirement.
On August 10, 2021, following the appeal of an unfavorable trial court ruling, the Missouri Supreme Court issued a unanimous decision in favor of the plaintiffs, thus requiring the Missouri Department of Social Services to comply with the Missouri constitutional requirement to expand Medicaid coverage to low-income individuals with incomes at or below 138% of the federal poverty level.
Working to Get People Enrolled
Unfortunately, Missouri was slow to enroll people in coverage. While the State began taking applications shortly after the Missouri Supreme Court decision, eligibility determinations did not start until October 1, 2021 (with coverage retroactive to July 1), and the State only enrolled a few thousand adults per week. The State’s eligibility and enrollment systems were ill-equipped to deal with the influx of new applicants for expansion coverage on top of the many thousands transferred from the federal “Hub” during the open enrollment process. Like many other states, Missouri experienced significant staffing shortages due to COVID and other factors, along with old-fashioned computer systems and a dysfunctional call center. These structural challenges to enrolling thousands of new enrollees contributed to a considerable backlog of Medicaid applications in excess of federally mandated time frames for processing applications.
Enrollment continued at a snail’s pace for the first several months, with increased pressure mounting on the Missouri government from advocates, providers, prominent health foundations, and the media. LSEM assisted clients and community partners with the enrollment process and identified procedural barriers to enrollment. We participated in multiple stakeholder meetings and advocated for a wide range of strategies to pick up the pace of enrollment.
LSEM engaged in direct discussions with the Missouri Department of Social Services and also turned to the federal Medicaid agency – the Centers for Medicare and Medicaid Services (CMS) to address the systemic dysfunction pervading Medicaid enrollment in Missouri. LSEM worked with the National Health Law Program to connect with the right people at CMS to discuss the problems and potential solutions. On July 11, 2022, CMS and the State of Missouri entered into a “Mitigation Plan” to correct deficiencies and implement a more streamlined approach to Medicaid application processing.
The agreement included strategies that LSEM had been recommending for a long time, such as reliance on SNAP data for expansion enrollment, enrolling parents based on their children’s Medicaid eligibility, and moving people directly from limited benefits programs into the adult Medicaid expansion. One of the more significant agreements was for Missouri to become a temporary “determination” state whereby it would accept eligibility determinations made by the federally facilitated Marketplace as long as the requisite verification accompanied those determinations. Through these mechanisms, the use of overtime, additional hiring, and systems upgrades, the Department of Social Services finally reduced the backlog and reported coming into compliance with CMS requirements in September 2022.
Building on Our Success and Looking Ahead to Future Challenges
A key question going forward is whether Missouri can sustain its recent progress, especially during the next “open enrollment” for the federal Marketplace. An even more daunting question is whether Missouri can handle the processing of new Medicaid applications when the Public Health Emergency (PHE) is over, and the State has to process applications and renewals simultaneously.
Despite these significant challenges, it is important to celebrate successes when they happen. As of this writing, with little or no advertising and seemingly insurmountable barriers, over 260,000 people are already enrolled in Medicaid expansion in Missouri. As a result of the efforts of LSEM, its legal partners, and a wide range of stakeholders, thousands of low-income Missourians have access to health care through Medicaid, often for the first time.
People long shut out of the health care system now have access to both immediate life-saving treatment and preventative care that will save millions of dollars and lives in the long term. Medicaid expansion will also improve health outcomes and reduce racial disparities in access to health care, as in other expansion states. Working with NHeLP on its “Medicaid Monitoring Project” has helped to capture the powerful impact of expansion. As one project participant noted:
When I was told that there was a new Medicaid program that I could apply for, I was skeptical due to my past experience. But I am glad that I decided to accept the help to apply for this program. I am now scheduled for surgery, and I can finally afford the medicine that can help me manage my pain. My life feels completely different right now. I cannot wait until the day that I can get through the workday with very little pain. Thank you to all the people who made this possible, I am forever grateful.
It is gratifying to have engaged in litigation with such a significant impact and that LSEM was instrumental in this remarkable victory. Moreover, our work on implementation (and resulting improvements to state practices) will pay off during the unwinding of the Public Health Emergency, when many of our clients will be at risk of losing coverage. LSEM will continue to be there to assist its clients, identify problems, and propose solutions to barriers to health coverage that unfold during the unwinding process. And we know we will have the support of the National Health Law Program through our ongoing Health Law Partnership.
Working Better Together Blog Series
The Working Better Together blog series gives our Health Law Partners a platform to highlight successes, challenges, and innovative approaches to furthering health access and health equity in the states where they work. Find other blogs in the series here.