Thursday, December 08, 2022

End of public health emergency could cause spike in uninsured Missouri children

By Clara Bates

The rate of uninsured children in Missouri stabilized during the COVID-19 pandemic, reversing a years-long trend that saw an increasing number of children losing coverage, according to a report released Wednesday by Georgetown University.

But the researchers warn the end of the federal public health emergency, which will likely occur next year and require states to redetermine eligibility for all Medicaid recipients, will put children at risk of inappropriately losing healthcare coverage.

Missouri was previously identified as one of six states where children are at the highest risk of losing coverage once the public health emergency ends.

Wednesday’s report, conducted by Georgetown’s Health Policy Institute Center for Children and Families, found a majority of states from 2019 to 2021 saw a decline or stability in their child uninsured population, in large part due to federal restrictions on states barring them from removing Medicaid recipients from their Medicaid rolls during the public health emergency.

Missouri’s rate of uninsured children was 6.5% in 2019 and declined to 5.9% in 2021, according to U.S. Census data. The Georgetown University report analyzed 2019 and 2021 federal data, as 2020 data was not made available.

Missouri had a higher prevalence of uninsured children than the national average in both years. Approximately 86,000 Missouri children were uninsured in 2021.

In the three years leading up to the pandemic, rates of uninsured children had gone up nationally for the “first time in recent memory,” a Georgetown press release noted. This was also the case in Missouri: According to federal data, Missouri’s rate of children lacking insurance coverage rose from 4.8% in 2016 to 6.5% in 2019.

"Procedural disenrollments"

Missouri’s social service department came under criticism in 2019 for significant Medicaid enrollment declines, after they adopted a new renewal process and information system.

Missouri Budget Project that year found that families were often kicked off Medicaid despite being eligible for coverage because of challenges with the renewal process, including that they did not receive the proper paperwork or submitted the paperwork only for it to be lost or not processed.

There were also hours-long waits for the Medicaid call centers at the time.

Advocates worry that once the public health emergency ends, Missouri could return to a situation in which the renewal process strips eligible Medicaid recipients of coverage due to administrative barriers.

In a study earlier this year, Georgetown researchers estimated 6.7 million children across the country are at risk of losing coverage when the public health emergency ends. The federal government predicted nearly three-quarters of children who are removed from the Medicaid rolls after the public health emergency ends will remain eligible but be dropped due to procedural issues.


“We often hear that procedural disenrollments occur when enrollees ‘fail’ to renew,” noted a Center for Children and Families post in August, “But it’s often a ‘system failure.’”

When children become uninsured, they’re more likely to experience worsening chronic conditions, miss well-child check-ups, and their families can receive high medical bills and even go into medical debt, Joan Alker, director of Georgetown’s Center for Children and Families and the lead author of Wednesday’s study, said on a press call Wednesday.

Missouri children are particularly at risk, Georgetown’s earlier report noted, because the state does not have a policy to provide 12-month continuous Medicaid coverage to children and also administers Children’s Health Insurance Program (CHIP) in a way that could lead to coverage gaps, including by charging families premiums for CHIP.

Alker said by email that Missouri has a “history of red tape losses for children,” referring to bureaucratic hurdles which create coverage gaps for eligible children. She credited the continuous coverage provision during the public health emergency with helping tamp that down.

The report’s finding that rates of uninsured children nationally declined slightly over the pandemic is “welcome news for America’s children,” Alker said in Wednesday’s press call but it “may be short-lived.”

Nationally, “millions of eligible children will likely fall through the cracks and become uninsured in states that are inattentive or ill-intentioned when the federal continuous coverage protection expires,” Alker continued.

The federal government has not yet announced when the PHE will end, but will give 60 days notice, and once it does end, states have up to 14 months to determine eligibility of all Medicaid enrollees.

Missouri’s social service department has told the MO HealthNet oversight committee it plans to take one year to complete all renewals.

Missouri’s social service department did not immediately respond to a request for comment.

In July, the state adopted several federal flexibilities designed to reduce their Medicaid application backlog in advance of needing to renew the entire caseload of Medicaid participants once the public health emergency ends.

Those flexibilities will be in place until the end of the public health emergency unwinding period, and could ease verification hurdles. One measure, which focuses on applications received through the federal marketplace, allows the state to accept the federal information rather than needing to re-verify it.

Missouri social services officials have also said the agency is working to ensure it has updated address information for participants so it can reach them when the public health emergency ends and renewals begin again.

At an August MO HealthNet meeting, director of Family Support Division, Kim Evans, said the state is working with managed care providers to update patients’ information in their eligibility system if they have moved. They are also doing social media blasts to remind participants to update their contact information and working to shift to an electronic notification system, Evans said.

Most adults in Medicaid-enrolled families nationally are not aware their services will be renewed again soon, an Urban Institute study last month found, posing challenges to states to reliably communicate the coming shift.

Unlike 35 other states, Missouri has not yet publicly provided its plan for the public health emergency unwind or a plan summary, according to Georgetown’s unwinding tracker.

Enrollment challenges

Missouri is working to replace outdated technology, Robert Knodell, director of the department of social services, explained at a press briefing in August.


There have been longstanding tech problems within Missouri’s social services department, which have left many processes manual — relying on paper forms — and burdened participants.

A 2020 report from the Missouri Department of Social Services and the nonprofit Civilla on enrollment challenges for benefits programs concluded that for participants, “the system feels like a secret and no one has the answer.” For staff, the report concluded, they feel “like an assembly line rather than connected to the people they serve,” and the work feels “siloed.”

Children in states who “have not kept pace with modernizing their eligibility system” are at greater risk of inappropriately losing coverage, Alker said Wednesday.

Deborah Greenhouse, a pediatrician in South Carolina and a member of the American Academy of Pediatrics Committee on Federal Government Affairs, said at the press briefing Wednesday that ongoing surges in pediatric respiratory illnesses and the child mental health crisis make continued coverage for children especially necessary.

“Any disruptions in coverage,” Greenhouse said, “would add another layer of crisis to an already dire situation.”

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