Saralyn Erwin has been a certified application counselor for close to a decade. She helps patients at the Northeast Missouri Health Council in Kirksville navigate the often complicated process of accessing social services, like Medicaid. And the legislative and legal fights over Medicaid expansion have only added to the confusion.
"It's been kind of like a rollercoaster," Erwin explained. "Yes it’s going to happen, no it’s not, it’s going to court and then yes it’s going to happen."
After a judge ordered Missouri to follow through with voter-approved expansion, an estimated 250,000 Missourians now qualify for the service. Under expansion, Medicaid covers people making up to 138 percent of the federal poverty level. Many of those newly eligible for the program have questions Erwin can’t answer yet.
"It’s hard to tell the public, because there’s so much that is still not really set in stone as far as how the process is going to work," Erwin said.
And Erwin is not alone. She has been meeting virtually with other application counselors and social workers from across the state who have raised a wide range of questions. They've asked about when coverage will start for new applicants and what care will be covered under expansion.
The answers to many of those questions will depend on the Family Support Division of the state Department of Social Services, which has said it needs another month to get the program up and running. Erwin said last she heard, the agency had already received more than 4,000 applications.
But for Erwin, there's a bigger question: are people aware Medicaid expansion is actually happening?
The state has done next to nothing to advertise expansion, outside of a court-ordered notice on the website for Missouri’s Medicaid service, called MO Healthnet. That means many of those who now qualify for coverage might not even know it.
Non-profits, healthcare providers and local health departments are trying to pick up the slack when it comes to outreach.
Steve Hollis is the Human Services Manager at the Columbia/Boone County Public Health and Human Services Department. He said the department is working on getting the word out. But like many other local health departments in Missouri, it’s been stretched thin by the Delta-variant-driven surge in COVID-19 cases.
“So on our end, it’s probably going to be more electronic communication with our partners just reaching out to the people we serve," Hollis explained. "That includes people that we’re communicating with about disease investigation and contact tracing.”
Medicaid expansion has been the biggest change Hollis has wanted to see in the state for years and he is excited for the possibilities.
Missouri is one of the last states to expand Medicaid eligibility through the Affordable Care Act. According to Manatt Health Senior Managing Director Patricia Boozang, that presents another obstacle to getting people enrolled. “Because you have a lot of people that think like, ‘I’ve been there, I’ve tried that, I’ve applied before, I’m not eligible.'”
Boozang advises states on Medicaid expansion design. She has seen other states find innovative ways to get people enrolled, including using the Children’s Health Insurance Program, or CHIP.
“Some states when they were expanding late took their CHIP program rosters, looked at who their parents were and did outreach to their parents to say 'Hey, looks like you’re eligible for Medicaid now.'”
And the state has an incentive to get people enrolled — the federal government covers 90 percent of costs for expansion enrollees, compared to just 60 percent for existing recipients.
But there’s a lot Missouri has to work out in the meantime. The Department of Social Services says it needs to update the complex computer systems used to manage enrollment, and it wasn’t budgeted enough by the legislature.
For her part, application counselor Erwin understands the delay. She believes state officials are working hard and in good faith. “But I also understand that there are individuals out there that need coverage," Erwin said.
The question of when they’re going to get that coverage is still up in the air.
This story is part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.
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