Kathreen Friend is a pediatric registered nurse based in Doniphan, Missouri — a small town of about 1,800, just 15 minutes north of the Arkansas border. As the lone pediatric specialist in her county, it’s not unusual for her days to fill up with appointments.
“I see a large volume of kids every single day,” Friend said. “It makes for long hours and long days, but we try to get people taken care of.”
Friend’s clinic is housed in the county’s former hospital, which closed in 2018.
It’s a one-stop shop for a range of ailments, from broken bones to ear infections to COVID-19. And according to Friend, most of her patients are Medicaid recipients. More than 2,200 children in the county of 10,000 receive some sort of public health coverage.
Millions of children across the U.S. rely on federal services, including the children’s health insurance program and Medicaid, for health coverage. Since the start of the pandemic, a federal emergency declaration has allowed them to receive continuous coverage — without jumping through the usual bureaucratic hoops.
Medicaid enrollment in Missouri has grown by more than 400,000 since the start of the pandemic. That’s one of the biggest per-capita increases in the country, largely driven by the state’s decision to expand Medicaid eligibility last year.
Normally, Medicaid recipients have to regularly prove they still qualify for the program, a process called redetermination that involves a lot of paperwork. Thanks to a federal emergency declaration, new recipients haven’t had to worry about that.
But some experts say Missouri’s track-record is cause for concern when the public health emergency declaration ends.
Concerns about coverage gaps
Dr. Maya Moody, president of the Missouri chapter of the American Academy of Pediatrics, worries about history repeating itself.
She remembers in 2019, some 100,000 children lost health coverage.
“I mean, we were turning away kids left and right and it just broke our hearts,” Moody said.
The state had recently started redeterminations after a long pause, and many children who still qualified were taken off the rolls.
“These are kids that we needed to see and they were our routine patients,” Moody said. “These are families that we know really well, and so … one of the true blessings of the public health emergency is we haven’t had to turn anyone away.”
The state later said there was an error, where if parents in a household lost coverage, their children did as well, despite children’s coverage having a much higher income threshold than that of adults. State officials say they’ve fixed this error. Nevertheless, Moody is concerned, and she’s trying to get ahead of any possible issues.
“We have already started to talk to folks about making sure they’re getting their documents together and they’re ready to reapply” once the emergency declaration expires, Moody said.
Complicating matters is that until recently, Missouri was taking months to process Medicaid applications.
According to a July report, the Missouri Department of Social Services had more than 40,000 pending applications, and it was taking more than 100 days to process each one, on average.
That’s more than double the time the federal government allows.
Avoiding the worst-case scenario
While officials say Missouri has cut down its backlog of Medicaid applications, the state has not disclosed information about its processing time except to say that it is now within the 45-day federal requirement.
Long processing times can mean long waits for children to get care. And avoiding that scenario means work on the front end for state agencies.
Sara Collins, a senior scholar with the Commonwealth Fund, said that’s an uphill battle. Collins focuses on insurance coverage in her research, and she’s been watching the emergency declaration closely.
“States are going to be faced at the end of the public health emergency with a gargantuan task of redetermining eligibility for people who have stayed on Medicaid over this two-year period,” Collins said.
According to Collins, states like Missouri that have faced staffing issues during the pandemic are worse off.
Because of that, the federal government has recommended a gradual approach for states to take on their caseload in chunks.
A spokesperson for the Missouri Department of Social Services said in an email the agency is currently working on verifying recipients’ addresses to make sure people get the eventual paperwork.
All that paperwork concerns Friend, the pediatric nurse in Doniphan. She worries especially about her patients who got covered during the state of emergency and have never had to go through redeterminations.
“And so now that it’s just easy … then they’re going to think they just keep getting coverage,” Friend said.
Educating her patients will be key to making sure the end of the public health emergency doesn’t keep kids from getting the care they need.
The public health emergency declaration is currently set to expire in October, but experts expect it to be renewed. U.S. Department of Health and Human Services Secretary Xavier Becerra has said his agency will give 60 days notice before ending the declaration. HHS gave no such notice in mid-August, likely signaling the agency plans to renew the declaration for another 90 days next month.