A staffer at a community health center in Carson City, Nevada, Madore spends her days helping low-income residents understand their health insurance options, including Medicaid. Her phone is always ringing, she said, as she fields calls from clients who dial in from the state’s remote reaches seeking help.

It’s a big job, especially this year as states work to sort through their Medicaid rolls after the end of a pandemic-era freeze that prohibited disenrollment.

A few dozen specialists work for seven navigator organizations tasked with helping Nevadans enroll in or keep their coverage. Madore said she mostly works with people who live in rural Nevada, a sprawling landmass of more than 90,000 square miles.

Katie Charleson, communications officer for Nevada’s state health marketplace, said it’s always a challenge to reach people in rural areas. Experts say this problem isn’t unique to the state and is causing concern that limited resources will throw rural Americans into jeopardy as the Medicaid unwinding continues.

KFF’s Medicaid Enrollment and Unwinding Tracker shows that who have lost Medicaid coverage since states began the unwinding process this year were disenrolled for procedural reasons, not because officials determined they are no longer eligible for the joint state-federal health insurance program.

By late August, directed state Medicaid overseers to pause some procedural disenrollments and reinstate some recipients whose coverage was dropped.

Experts say those procedural disenrollments could disproportionately affect rural people.

A by researchers at the Georgetown University Center for Children and Families noted that rural Medicaid recipients face additional barriers to renewing coverage, including longer distances to eligibility offices and less access to the internet.

Nationwide, Medicaid and CHIP, the Children’s Health Insurance Program, covered 47% of children and 18% of adults, respectively, in small towns and rural areas, compared with 40% of children and 15% of adults in metropolitan counties.

“As is clear from our research, rural communities rely on Medicaid to form the backbone of their health care system for children and families,” said Joan Alker, who is one of the brief’s co-authors, the executive director of the Center for Children and Families, and a research professor at Georgetown’s McCourt School of Public Policy. “So if states bungle unwinding, this is going to impact rural communities, which are already struggling to keep enough providers around and keep their hospitals.”

A lack of access to navigators in rural locales to help Medicaid enrollees keep their coverage or find other insurance if they’re no longer eligible could exacerbate the difficulties rural residents face. whether they’re eligible for Medicaid or CHIP, coverage for children whose families earn too much to qualify for Medicaid, and help them enroll. If their clients are not eligible for these programs, navigators help them enroll in marketplace plans.

Navigators operate separately from Nevada’s more than 200 call center staffers who help residents manage social service benefits.

Navigators are required by the federal government to provide their services at no cost to consumers and give unbiased guidance, setting them apart from insurance broker agents, who earn commissions on certain health plans. Without them, there would be no free service guiding consumers through shopping for health insurance and understanding whether their health plans cover key services, like preventive care.

Roughly 30 to 40 certified enrollment counselors like Madore work at navigator organizations helping consumers enroll in plans through Nevada Health Link, the state health marketplace, which sells Affordable Care Act plans, said Charleson. One of these groups is based in the small capital city of Carson City, 30 miles south of Reno, where fewer than 60,000 people live. The rest are in the urban centers of Reno and Las Vegas.

Availability of navigators and their outreach tactics vary from state to state.

In Montana, which is larger than Nevada but has one-third the population, six people work as navigators. They cover the entire state, reaching Medicaid beneficiaries and people seeking help with coverage by phone or in person by traveling to far-flung communities. For example, a navigator in Billings, in south-central Montana, has worked with the Crow and Northern Cheyenne Tribes, whose reservations lie relatively nearby, said Olivia Riutta, director of population health for the Montana Primary Care Association. But officials struggle to reach northeastern Montana, with its Fort Peck Reservation.

Having navigators in rural communities to help people in person is an ongoing challenge the country faces, said Alker. But the unwinding circumstances make it an especially important moment for the role navigators play in guiding people through complex insurance processes, she said.

This became clear following a regarding what consumers encounter when independently searching for health coverage on Google. “The results are really concerning,” said survey co-author JoAnn Volk, a research professor and the founder and co-director of the Georgetown University Center on Health Insurance Reforms.

The researchers found that former Medicaid enrollees looking for health plans on the private market face aggressive, misleading marketing of limited-benefit products that don’t cover important services and fail to protect consumers from high health costs.

Researchers shopped for coverage using two profiles of consumers who were losing Medicaid coverage and were eligible for a plan with no premiums or deductibles on the ACA marketplace.

The team reported, though, that none of 20 sales representatives who responded to their queries mentioned that plan, and more than half pushed the limited-benefit products. The representatives also made false and misleading statements about the plans they were touting and misrepresented the availability or affordability of the marketplace plans.

The sales reps and brokers quoted limited plans that cost $200 to $300 a month, Volk said. Such an expense could prove unaffordable for consumers who may still be low-income despite being ineligible for Medicaid.

“If they can’t get to a navigator, I would not trust that they would get to their best coverage option in the marketplace, or to the marketplace at all, frankly,” Volk said.

Making a difficult problem more challenging, the federal government does not require states to break down Medicaid disenrollment data by county, making it harder for experts and researchers to track and differentiate rural and urban concerns. The Center for Children and Families does so with data from the Census Bureau, which Alker pointed out won’t be available until next fall.

A data point that will be important to watch as states continue the redetermination process, Alker said, is call center statistics. People in rural areas rely more heavily on that method of renewing coverage.

“Call abandonment rate” is one such statistic. CMS defines it as the percentage of calls that drop from the queue in two separate measures — calls dropped up to and including 60 seconds, and calls dropped after 60 seconds. In August, the agency to the Nevada Department of Health and Human Services about its rate: An average of 56% of calls dropped in May, the first month after Nevada’s unwinding began.

The agency “has concerns that your average call center wait time and abandonment rate are impeding equitable access to assistance and the ability for people to apply for or renew Medicaid and CHIP coverage by phone and may indicate non-compliance with federal requirements,” said Anne Marie Costello, deputy director of CMS.

In the letter, Costello also cited the 45% of Medicaid enrollees whose coverage was terminated for procedural reasons in May.

All about early data, but only Idaho, South Carolina, Texas, and Utah had higher disenrollment rates than Nevada, and no state had a higher rate of call abandonment.

Officials at Nevada’s Division of Welfare and Supportive Services said its call center, staffed by 277 family service specialists, receives more than 200,000 calls a month. A spokesperson said the phone system offers self-service options whereby customers can obtain information about their Medicaid renewal date and benefit amounts by following prompts. Because those calls aren’t handled by a case manager, they are considered “abandoned,” the spokesperson said, raising the rate even though callers’ questions may have been fully addressed.

People shopping around for coverage after a lapse might go into a panic, Madore said, and the best part of her job is providing relief by helping them understand their options after disenrollment from Medicaid or CHIP.

When people find out the wide range of free services navigators like Madore offer, they’re shocked, she said.

“They’re unaware of how much support we can provide,” Madore said. “I’ve had people call me back and they say, ‘It’s my first time using insurance. Where do I go to urgent care?’”

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“I’d probably not be able to work that much because I’d be tired but couldn’t fall asleep,” he said.

Murray’s mother is paying $1,548 more than usual in health insurance premiums over three months to make sure he can afford his sleeping pills, other medication, lab work, and doctors’ appointments.

Murray had to scramble to find an insurance option after he was surprised to lose his Medicaid coverage on April 1 — even though he will likely requalify July 1.

Due to a convoluted situation in South Dakota and North Carolina, Murray isn’t the only person who will experience this whiplash in Medicaid coverage.

Medicaid is the joint federal and state health insurance program for people with low incomes or disabilities. During the national covid-19 public health emergency, states were barred from removing people from the program even if they no longer qualified.

This rule has now ended, and states can redetermine whether Medicaid participants still qualify. The federal government Americans will lose coverage under Medicaid or the Children’s Health Insurance Program because they no longer qualify or because of paperwork issues.

But as South Dakota and North Carolina remove participants from Medicaid, the states also plan to add people to the program. That’s because South Dakota voters and recently approved Medicaid expansion, which will increase the number of people eligible for the program.

“It would have been great if they would have kept people on until the expansion, so you’re not kicking so many people off,” said Kathy Murray, Jonathon’s mother.

South Dakota could have tried to prevent participants from temporarily losing Medicaid coverage, according to several health policy experts.

State officials are “saying federal regulations mean that they have to kick people off before expansion, and that’s just not right,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University. “They absolutely could be structuring this in a way that those people didn’t experience a loss in coverage.”

Lucy Dagneau, head of Medicaid campaigns for the American Cancer Society Cancer Action Network, agreed. South Dakota and North Carolina “can’t actually stop the process of the unwinding. However, they have flexibility in terms of how they batch the enrollees,” she said.

Alker and Dagneau said states don’t have to start the unwinding process right away, and when they do, they could delay reviewing enrollees who are likely to requalify under expansion.

South Dakotans and North Carolinians who want to avoid a gap in health care coverage can apply for private insurance, which could be subsidized under the Affordable Care Act. They could then reapply for Medicaid once applications for expansion coverage begin. But if they wind up uninsured during the gap period, they might avoid seeking treatment or face expensive bills.

South Dakota is that began culling April 1, the earliest date possible. Its Medicaid expansion goes into effect July 1. About 16,000 South Dakotans were disenrolled in April, but more than 1,700 of them will requalify under expansion, .

North Carolina will begin disenrolling people who are no longer eligible for Medicaid on July 1. The state has not set a timeline for Medicaid expansion, but it’s expected to occur within the unwinding period, which lasts through May 2024.

Jay Ludlam, deputy secretary of North Carolina’s Medicaid program, said the uncertain timing makes it difficult to avoid temporarily disenrolling people. Ludlam said about 300,000 North Carolinians are expected to be removed from Medicaid during the unwinding. He estimated one-third of them will requalify after expansion.

Kathy Murray added Jonathon to her workplace insurance plan, which will more than double her premiums over the intervening months. She said she won’t be able to pay some other bills during this time, but her son can’t go without health care.

She said South Dakota’s approach seems inefficient, since state workers will have to disenroll and reenroll some people within a short period. “It’s creating a lot of work for the state workers because they’re going to send out paperwork and requalify everybody,” she said.

Matt Althoff, secretary of the South Dakota Department of Social Services, said that the agency’s unwinding plan is “based on compliance with CMS rules, limitations of the technology used to support South Dakota Medicaid, and the overall impact to customers.”

The agency wrote in a that it was working closely with the federal Centers for Medicare & Medicaid Services “to explore waivers and flexibilities during the period of the unwinding prior to expansion and will continue to do so.”

Althoff did not respond when asked by Ñî¹óåú´«Ã½Ò•îl Health News whether the state had discussions with the federal agency about avoiding temporary disenrollments. Sara Lonardo, press secretary for CMS, said the agency could not comment on whether it had any related conversations with South Dakota or North Carolina officials.

Although South Dakota won’t prevent people likely to requalify for Medicaid from temporarily losing coverage, it is taking steps to make sure they know to reapply.

The state is screening people who no longer qualify for Medicaid under the current rules to see if they would requalify after Medicaid expansion. If so, they should be sent letters .

Since 2014, the Affordable Care Act has allowed states to offer Medicaid coverage to more people, with the federal government paying 90% of the costs. All but .

South Dakota adults currently qualify for Medicaid if they have a certified disability or have children and incomes up to 46% of the federal poverty level. That translates to $13,800 for a family of four.

Jonathon Murray qualified for Medicaid as a child. But he became an adult during the public health emergency and thus no longer qualifies.

Medicaid expansion will allow adults, with or without children, to enroll in the program if they earn up to 138% of the federal poverty level, or $20,120 for a single adult. Murray’s income as a part-time restaurant cook and dishwasher should allow him to requalify and begin receiving Medicaid coverage on July 1.

Get Covered South Dakota helps people understand and apply for health care insurance. So far, everyone the organization has assisted after being disenrolled from Medicaid has qualified for subsidized private plans under the Affordable Care Act’s marketplace, according to program manager Penny Kelley. For people with low incomes, the subsidies can cover most or all of their premiums.

South Dakota Voices for Peace, a nonprofit agency, is assisting people with the Medicaid unwinding and expansion process. Carla Graciano, its outreach coordinator, said many people are confused about the unwinding process after not having to worry about health coverage for more than three years during the public health emergency.

“We have heard concerns about people potentially losing their medical coverage,” Graciano said. “It puts a lot of people under stress.”

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It started in places like Livingston, a town of 8,300 where, in 2018, Western closed an outpatient treatment clinic and to travel 30 miles over a mountain pass to Bozeman for stabilizing mental health care. This spring, Western closed that clinic too, a crisis center in one of Montana’s fastest-growing cities.

The private nonprofit’s initial closures were attributed to made in 2017. Since then, Western’s financial troubles have spiraled. It cut jobs or retrenched services every year since 2019. In February, Western closed three mental health crisis centers, leaving just two others to serve the rural 147,000-square-mile state.

Western’s money problems have built slowly and are due largely to low reimbursement rates from Medicaid, staffing strains, and rising costs. Former Western board members and employees say poor management has also played a role. The company has said it is losing money by subsidizing crisis services for the state.

“We’ve become the face of the failure of the system because we’re the only organization providing these services,” said Levi Anderson, Western’s CEO.

The decline illustrates a national problem: a U.S. health care system that doesn’t adequately pay for mental health care. Clinics nationwide have shuttered programs they can’t afford and left beds empty that they can’t staff.

“Those are the kinds of stories that I hear every week from every part of the country,” said Chuck Ingoglia, CEO of the National Council for Mental Wellbeing. “More people are experiencing depression and anxiety and are in need of care, and we have this corresponding reduction in capacity. It’s a perfect storm.”

Cracks in Montana’s system have shown up elsewhere. Community clinics can’t compete for staff. Private practice therapists have months-long waitlists. The Montana State Hospital — a public psychiatric hospital and the fallback when local services aren’t enough — lost federal funding after staffing shortages and mismanagement led to .

Policymakers for behavioral health care statewide through bills and budget measures. Health professionals, while hopeful, are skeptical that an influx of cash is enough to create lasting changes.

Community crisis centers are a safety net when someone’s mental health spirals, leading to suicidal thoughts or disconnection from reality. They provide services to stabilize patients and prevent recurring crises.

Western opened such centers in Butte, Bozeman, Helena, Kalispell, Polson, Missoula, and Hamilton starting in 2010.

“Of all of the crisis houses in the state, every one of them was started and operated by Western,” said Tom Peluso, a longtime mental health advocate and former board director for Western. “Nobody else was willing to make the investment.”

Still, almost every community in Montana lacked crisis stabilization services, according to a released last year. Emergency rooms and the state hospital became ill-equipped alternatives.

Most of Western’s patients rely on Medicaid, a federal-state health coverage program for people with low incomes or disabilities. Health professionals have long said Medicaid’s state-set payments don’t cover the cost of care, which a

Anderson said crisis services never made money. Until recently, Western could rely on other programs to make up the difference, such as case management, which links patients to ongoing care.

In 2017, the state roughly halved Medicaid’s reimbursement for case management. By 2019, more than it earned.

Then came the covid-19 pandemic, which disrupted school-based mental health services, another Western revenue source, as learning went remote. Simultaneously, competition for health workers spiked, meaning Western had to increase pay or ratchet back services with fewer employees.

In 2020, the company whittled its school-based programs, of mental health workers, and closed at least two sites. In 2021, it emptied a group home in Hamilton and listed two large affordable housing units for sale. Last year, Western closed a and struggled to staff its remaining crisis centers.

As services faltered, so did people’s trust in Western. That included Peluso, who left the company’s board last year after roughly two decades. In his resignation letter, Peluso wrote that selling assets “is not a business plan.”

Kathy Dunks, a Western employee for 29 years in Butte, felt a shift around 2018, when Anderson and other new leaders arrived soon after the company’s longtime CEO retired.

“It was the first time it felt like, ‘If you don’t like it, leave,’” Dunks said.

She was laid off in 2019, when Western replaced regional leaders with managers to oversee company-wide programs. Dunks turned down a new role with Western, saying she no longer trusted the company.

Anderson said the goal was to standardize treatment among sites and save money. Around the same time, some of the company’s highest-paid employees got raises, which Anderson said likely happened to retain top-trained staffers at the time.

Anderson said that the company is balancing services clients need with remaining viable and that it tries to incorporate employees’ feedback. He said management restructuring led to some turnover, but the pandemic and low funding exacerbated long-standing pressures.

At its peak, 17 counties paid Western to provide local services. As the company struggled, the participating counties dropped off to just one as of this year.

In 2020, Anaconda-Deer Lodge County ended its contract with Western, which helped it provide crisis response and psychiatric evaluations.

“We started running into problems with them saying, ‘Well we don’t have anybody who can come out now, we’ll send out somebody in the morning,’” said County Attorney Ben Krakowka. “That doesn’t work when somebody’s in crisis now.”

In late 2019, it would end its contract with Western to provide services in its detention center. County officials said they’d hire their own staff for better access to data and more control. The county also announced it would seek applicants for its crisis response team, a service Western provided.

Western cut ties with the county altogether, including closing the area’s sole crisis facility. Anderson said the company had been clear: Western needed to provide a continuum of care to do its job well.

While Lewis and Clark County has filled some gaps since, its crisis house remains closed. The one company that applied for the job determined reimbursement rates would cover only half the costs.

Some jurisdictions, like Gallatin County, which with Western in 2022, plan to open crisis facilities with different providers at the helm. Anderson said new vendors alone can’t fix Montana’s problems.

“Our current state is not a result of Western not knowing how we could provide good care,” Anderson said. “The current state is a result of the state not funding good care.”

Lawmakers are that would spend $300 million over several years toward behavioral health care system. They’re also considering a constitutional amendment . That would be in addition to a fund Republican Gov. Greg Gianforte created to fill gaps in mental health care, though some details remain undecided and competition for those dollars will be high.

State representatives also proposed to raise Medicaid reimbursement rates by how much. Mental health workers have said adjusted Medicaid rates are only a stopgap, and crisis services can’t rely on those payments alone.

Montana state officials a statewide program to fund specially designated clinics that offer local mental health and substance abuse services — paying for the value of the care instead of each service independently.

“We’ve got to change the system,” said Mary Windecker, executive director of Behavioral Health Alliance of Montana.

The Montana Department of Public Health and Human Services received a federal grant to begin making plans to adopt that system. But if that change comes, it’s years out.

Meanwhile, mental health clinics are struggling to keep existing programs from further unraveling.

As for Western, Anderson said the center is still committed to serving clients. Western is using former crisis beds to expand group home programs and began accepting new residents in March.

For now, the company doesn’t plan to return to its former level of crisis services.

“The need is there,” he said. “We just can’t continue to subsidize the program.”

Western’s two remaining crisis centers are in Missoula and Ravalli counties — just 47 miles from each other in the vast state.

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It’s not Medicaid expansion, which Georgia Republican leaders have rejected. Instead, the state Department of Community Health is using an under-the-radar Medicaid funding opportunity that has been rapidly taken up by more than 35 states — including most of the states that have expanded the government insurance program.

The extra federal money comes through an obscure, complicated mechanism called “” — available only for states that hire health insurers to deliver services for Medicaid.

In 2020, these special funding streams, which are approved by federal health officials, sent more than $25 billion to states, according to the Medicaid and CHIP Payment and Access Commission (MACPAC), which advises Congress.

The Centers for Medicare & Medicaid Services, when asked for an updated total, referred KHN to individual states for their spending figures. “CMS has not publicly published total spending related to state directed payments,’’ said agency spokesperson Bruce Alexander.

But the Government Accountability Office, Congress’ watchdog agency, and MACPAC say federal health officials should do more to monitor directed payments and evaluate whether states meet the program’s goals, which include improved access and quality of care. More transparency is needed, these agencies said.

A found that fewer than 25% of directed payment plans running for at least a year had evaluations available for review.

Federal health officials “are getting a lot of questions” on directed payments from GAO and MACPAC, said Debra Lipson, a senior fellow at consulting firm Mathematica, which has studied the issue. “It’s a lot of money.”

CMS hasn’t yet released reports on quality metrics for the program, Lipson added.

Alexander, the CMS spokesperson, said the agency “takes our role in oversight and transparency seriously, and we are working collaboratively with our federal and state partners to improve our oversight and transparency” of directed payments.

Medicaid is the government health insurance program for low-income and disabled patients. It’s jointly financed by the states and the federal government.

CMS launched the directed payments program in 2016. Georgia officials estimated the state will net $1 billion in federal funds this fiscal year for hospitals and other medical providers through its directed payment programs.

California estimates it brought in more than $6 billion just last year in new federal funds through directed payments. Arizona received $4.3 billion between 2018 and 2022. more than $1 billion over a 12-month period ending in September.

This special Medicaid funding may indirectly help patients by strengthening financial stability for hospitals, along with offering the potential for capital improvements from the added cash infusions.

But patient advocates and Democratic lawmakers in Georgia said providing insurance coverage for the medical needs of the uninsured by adopting Medicaid expansion is more urgent. Hospitals, like Emanuel Medical Center, would benefit from Medicaid reimbursements for patients who now often rack up unpaid bills for care.

The uninsured “are not going to get preventive care, and that drives up health care costs,” said state Sen. Elena Parent, an Atlanta-area Democrat. “The state should have expanded Medicaid.”

That expansion is not going to happen in Georgia in the short run, as Republican Gov. Brian Kemp is set to launch new limits on Medicaid enrollment for low-income adults, with work requirements attached.

Under directed payments, added funding for hospitals and other Medicaid medical providers flows through different avenues, including minimum fees for services, a general reimbursement increase, and pay hikes based on quality of care.

Payments are based on the volume of services delivered. If one hospital served more Medicaid patients than another, its reimbursements would be higher, Lipson said.

“CMS initially was surprised by the volume of states’ directed payment proposals,” said Lipson. Some states have 25 or more, she added. They must be renewed annually. Often states finance their portion through hospital assessments or money transferred from public funds, such as hospital authorities, county governments, and state agencies.

Georgia has five such directed payment plans. Their goals include boosting Medicaid pay for hospitals and doctors, strengthening the health care workforce, and improving health outcomes and equity, said Caylee Noggle, commissioner of the state Department of Community Health, which runs Medicaid in Georgia.

Grady Memorial Hospital in Atlanta, a large safety-net provider, said it expects to gain $139 million across four of the Georgia programs.

“It’s a tremendous benefit for us,” said Ryan Loke, Grady’s chief health policy officer. “Without this money, Grady would be in a lot worse position.”

Grady is seeing more Medicaid and uninsured patients who formerly used nearby Atlanta Medical Center, which closed last year.

State Sen. Ben Watson, a physician and Savannah-area Republican, pointed out that such safety-net hospitals, which serve a large portion of people who lack health coverage, are getting higher pay through Medicaid directed payments, thus helping them cover some losses.

Georgia plans to use these funding streams as a base for extending extra help to rural hospitals.

With the extra payments, Grady and other hospitals will approach or reach their normal funding limit for hospitals that serve a “disproportionate share” of indigent patients. The state would take about $100 million of this excess money and send it to rural hospitals.

The Georgia Hospital Association said the directed payment money is helpful but won’t cover costs of charity care for the uninsured.

“They’re not looking at [hospitals’] bad debt,” said Anna Adams, an executive with the group. “An insured patient is a healthier patient. We’d love to see as many people covered as possible.”

Officials at rural hospitals in Georgia, meanwhile, are looking forward to the projected boost in Medicaid funds.

“It’s going to put cash in the coffers of rural hospitals that are struggling,” said Jimmy Lewis, CEO of HomeTown Health, an association of rural hospitals in the state.

Damien Scott, CEO of Emanuel Medical Center, said he’s “cautiously optimistic” about the coming allocation. On his wish list: attracting a pediatrician to his county — it has none currently — and gaining the space to move the hospital’s lone MRI machine from a truck into the hospital building.

As it is, he said, “we struggle every month for our survival.”

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Since 2016, has heard fewer than 20 cases a year, and very few of those are overturned, but preparing for those appeals and board meetings takes time from state Department of Public Health and Human Services’ staff members and attorneys, according to the

Getting rid of the appellate board also would help public assistance applicants who are rejected appeal their cases directly to district court, health department Director Charlie Brereton . Currently, rejected applicants can take their cases to court only after the board hears their appeals, though very few do so, according to a board member.

“I want to be very clear, with this proposal we are not seeking to eliminate an appeals pathway; rather, we’re streamlining the process and eliminating what we see as an unnecessary and underutilized step,” Brereton said.

The plan to get rid of the Board of Public Assistance is one of 14 bills that the state Department of Public Health and Human Services has asked legislators to draft for the . The proposal comes from a review of the state agencies under Republican Gov. Greg Gianforte’s , which seeks to improve efficiency and eliminate outdated or unnecessary regulations.

The three-person Board of Public Assistance presides over appeals of denials made by the health department’s Office of Administrative Hearings in nine programs: Temporary Assistance for Needy Families, which provides cash to low-income households with children; the Supplemental Nutrition Assistance Program, formerly known as food stamps; Medicaid, the federal-state program that pays for health care for low-income people; developmental disabilities services; the Low Income Energy Assistance Program; the Weatherization Assistance Program; refugee assistance; mental health services; and Healthy Montana Kids, which is the state’s Children’s Health Insurance Program.

The proposal to eliminate the board came as a surprise to at least one of its members, who learned about it from KHN. “I haven’t heard anything from the department,” said Sharon Bonogofsky-Parker, a Billings resident appointed by Gianforte in March 2021.

The board meets every other month, Bonogofsky-Parker said. She recalled one “really good case” during her tenure in which the board restored benefits to a disabled military veteran who had lost them because of documents forged by someone else.

But Bonogofsky-Parker estimated that the board sides with the department’s decisions about 90% of the time because most cases involve applicants who didn’t understand or follow the programs’ rules, whose income level changed, or who have some other clear disqualifying factor.

The board provides a service by hearing appeals that would otherwise clog the court system, she said. “By and large, these cases are pretty frivolous,” Bonogofsky-Parker said. “The board is useful in keeping a lot of these cases out of court.”

The view contrasts with Brereton’s, who described the ability of applicants to file court grievances expediently as a benefit of the proposed change.

District courts charge a $120 fee to start a proceeding of this type, according to the Lewis and Clark County District Court clerk’s office. That would create a potential obstacle for people trying to prove they qualify for public assistance. By contrast, Board of Public Assistance appeals are free.

State health department spokesperson Jon Ebelt said people with low incomes to request a court fee waiver. “This issue was considered during conceptual stages of the bill,” he said.

Bonogofsky-Parker said she doesn’t plan to oppose the department’s proposal, despite her view that the board acts as a bulwark against frivolous court cases. The other two board members, Gianforte appointee Danielle Shyne and Carolyn Pease-Lopez, a holdover from former Democratic Gov. Steve Bullock, did not respond to phone or email messages.

The Children, Families, Health, and Human Services Interim Committee will draft the bill for consideration by the full legislature in the 2023 session.

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A Cure for Ambulance Sticker Shock

This is a comment about your recent story on ambulance surprise bills (“The Ambulance Chased One Patient Into Collections,” July 27). In the story, three siblings were taken from an accident in three separate ambulances, then charged vastly different rates.

In Oklahoma City, we pay $3.65 a month on our water bills to fund EMSA (Emergency Medical Services Authority), a public ambulance service. If you need a ride in one, that premium covers it for anyone in your household. The payment is opt-out, so most everyone pays it. Non-water customers (like those in apartments whose rent covers utilities) can buy in, too. It might still be expensive for out-of-town visitors, however.

The EMSA premium works. You should report on it.

— Phil Crow, Oklahoma City, Oklahoma

— Dr. Richard Vaughn, St. Louis

Tough Lesson on Predatory Lenders

This essay (“The Debt Crisis That Sick Americans Can’t Avoid,” Aug. 2) compares student loan debt to medical debt but doesn’t seem to grasp how predatory the student loan industry is. For example, I have paid back close to $70,000 (more than I borrowed) and still owe $282,000.

There are thousands more in the same situation. It’s why we’re pushing for relief from the uniquely predatory and exploitive student loan debt.

— Brian Galloway, Salem, Oregon

— Ellen Fink-Samnick, Burke, Virginia

Focusing on FQHCs

This article paints a grossly inaccurate picture of federally qualified health centers (FQHCs) and their work delivering life-sustaining care to 30 million Americans (“Community Health Centers’ Big Profits Raise Questions About Federal Oversight, Aug. 15).

The piece’s conclusions are based on data representing fewer than 1% of health centers. Framing an argument on a cherry-picked handful of centers out of nearly 1,400 nationwide skews the facts.

Health centers fought on the front lines of the pandemic. Fewer people were infected with, or died from, covid-19 when a health center was nearby. Such efforts came at a cost: Most centers operate on thin margins, struggling to retain staff even while battling health crises.

Financial resilience for centers is essential because federal support has never been as certain as the challenges associated with caring for low-income communities.

The centers’ financial reserves are not secreted away but are regularly reported, available for scrutiny and subjected to annual audits. In some cases, dollars go toward site expansions, staffing, or expanded services. One lesson learned from the pandemic is that centers are the “canaries in the coal mine” of public health and require funding to nimbly adapt care. Private donations have also helped health centers stay afloat, a fact barely mentioned in KHN’s reporting.

The average health center CEO salary is far less than what this reporting on outlier centers suggests. There are far more profitable jobs in health care that do not involve fighting for every dollar to care for the underserved. For health center staff, it’s about dedication, not dollars.

KHN’s reporting amplifies misconceptions about the 340B prescription program — which has provided a crucial lifeline to uninsured and underinsured Americans who otherwise struggle to afford prescriptions. By law, all savings resulting from that program must be reinvested in patient care. As a result, health centers report vastly improved health outcomes among their patients.

Accountability is also baked into the health center model. Site visits by regulators ensure that patient care and clinical data is consistent with national standards. Additionally, health centers are governed by local boards, for which patients mostly serve as the directors.

The health center model has been quietly addressing every public health crisis for more than 50 years.

When most private-practice physicians limit or do not accept Medicaid patients, roughly half of health center patients are covered by Medicaid and would, without access to health centers, likely seek costlier emergency room services. As we continue to struggle with public health threats, health centers’ efforts to test, vaccinate and treat hard-to-reach populations deserve support and investment.

The National Association for Community Health Centers will continue to stand up for our valued health care heroes. No other health system stands as a living legacy that health care can be patient-driven, effective, and trusted stewards of federal dollars. We stand by this model.

— Rachel Gonzales-Hanson, interim president and CEO of the , Bethesda, Maryland

— Bijan Salehizadeh, Washington, D.C.

Mental Health for the Incarcerated: When Hands Are Tied

I am a psychologist and the director of mental health services for a medium-sized (around 800 inmates) jail in Indiana. I have been dealing with this frustrating problem for the past five years (“When Mental Illness Leads to Dropped Charges, Patients Often Go Without Stabilizing Care,” Aug. 4). We often run into this issue when police/prosecutors fail to file charges, and we’re stuck dealing with an inmate who is psychotic and homeless with no family. The local hospitals won’t take someone on an emergency detention order, or EDO, unless the individual is verbally saying they’re suicidal. With regard to the wait for a state psychiatric bed, we’re averaging four to five months now for forensic beds, and 11 months for civil commitment beds. I’ve seen inmates serve nine months or more (including time at the hospital) for a trespassing charge.

We’re often stuck in a situation in which we have to release someone who is psychotic and the hospital won’t take them. They usually have no family to help. This is extremely dangerous, especially in the winter months when it can drop below zero (all of the warming shelters in my area have closed since covid started). Sadly, the best outcome is that the patient refuses to leave the jail lobby and is arrested for trespassing and brought right back into the building.

Anyway, I wanted to say thank you for writing this article.

— William Mescall, Crown Point, Indiana

As lose jurisdiction with dismissal of charges, they lose control over defendants with and no longer be able to provide or mandate care. This creates a rapidly revolving door to and .

— Paul R Gormley LP.D. (@prgormley)

— Paul R. Gormley, Boca Raton, Florida

On Psychiatric Hospitalizations and Suicide Risk

I was disappointed to see that the author of the story “Social Media Posts Criticize the 988 Suicide Hotline for Calling Police. Here’s What You Need to Know.” (Aug. 11) implied that psychiatric hospitalization causes death by suicide in the following paragraph: “Research shows suicide rates increase drastically in the months after people are discharged from psychiatric hospitals. Those who were sent involuntarily are more likely to attempt suicide than those who chose to go, and involuntary commitments can make young people less likely to disclose their suicidal feelings in the future.”

While is it true that the period after psychiatric hospitalization is a key risk period for death by suicide, there is no causal evidence to demonstrate that the hospitalization causes death by suicide. In fact, there is an important third variable that may explain this finding: Only people who are severely ill, and often at high risk for suicide, are psychiatrically hospitalized. Indeed, for me, as a licensed psychologist, involuntary psychiatric hospitalization is a last resort for people at imminent risk of death by suicide.

You may wish to read a in which the researchers synthesized data from randomized control trials, or RCTS. RCTs are the gold standard for evaluating causality because they can rule out third-variable explanations, such as severity. Their article states: “Indeed, a small number of RCTs have examined means restriction/safety programs and acute psychiatric hospitalization. Notably, these interventions produced effects that are similar to those of more commonly studied interventions.” Overall in their meta-analysis, they did not find evidence that interventions for suicidality are iatrogenic or cause increased suicidality.

— K. Jean Forney, clinical psychologist and assistant professor at Ohio University, Athens, Ohio

Very much appreciate that this article included non-carceral resources. Once you’ve survived involuntary “care” you will never look at the system the same way.

— Kathy Flaherty (@ConnConnection)

— Kathy Flaherty, Middletown, Connecticut

“Say abortion” seems like a bad slogan, but wdik.

— Frank Bednarz (@FrankBednarz)

— Frank Bednarz, Chicago

Anti-Vaccine Mandate Is Not the Same as Anti-Vaccine

An important comment regarding your article “‘My Body, My Choice’: How Vaccine Foes Co-Opted the Abortion Rallying Cry” (July 6). It is purposely deceptive. You say “anti-vaccine” activists — which is incorrect. The people gathering in Los Angeles (and elsewhere across the country) are anti-forced vaccine — not necessarily “anti-vaccine,” as your article repeatedly insists. To be against being forced to submit to an experimental medicine is not the same as being against a vaccine — or those who choose to take it. You, of course know this: No medicine is right for everyone. Why are you deliberately choosing to deceive people by your careful, not-accidental choice of words?

— Kathleen German, Nashville

But the “COVID precautions” have ended. It is more like white nationalists trying to recruit new members.

— Derrick Edward Jones (@deuceohsixx)

— Derrick Edward Jones, Seattle

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Alarmed, Katie Lester called the Tennessee Medicaid agency, TennCare, which had covered her during a prior pregnancy and insured Mason since the day he was born.

TennCare said they were no longer enrolled because the family failed to respond to a packet of essential paperwork. But Lester hadn’t seen the packet, nor a termination letter. Years would pass before it became clear what went wrong: Due to a clerical error, TennCare had mailed both to a horse pasture.

The loss of Medicaid was catastrophic for the Lesters, an impoverished family that owns a small lawn-cutting business in Belfast, a town of 600 about an hour south of Nashville. Lester and her husband appealed TennCare’s decision but were rejected. They reapplied and were denied after mailed paperwork once again failed to reach their home. The Lesters said they were left uninsured for most of the next three years, during which the coronavirus, injuries, and a cesarean birth buried them under more than $100,000 of debt, which savaged their credit and dashed plans to buy their first home.

“It was like we just got run over by a bus when I found out we didn’t have insurance,” Lester said.

The Lesters’ story may be a warning of what’s to come for many poor Americans. Because of the covid-19 public health emergency, TennCare and Medicaid programs in other states largely have been barred from dropping anyone, and Medicaid enrollment has swelled to historical highs. But when the emergency is declared over, states will once again require families to prove they are poor enough to qualify for coverage. Millions are expected to lose their insurance in the year that follows, including countless people like the Lesters who meet the requirements for Medicaid but get lost in its labyrinthine bureaucracy.

“People are falling through the cracks. And we need something there to catch them before they are swallowed up in the abyss.”

Waverly Crenshaw Jr., chief judge of the U.S. District Court for the Middle District of Tennessee

Problems with the verification process have long shadowed TennCare, an agency that prides itself on keeping enrollment small and spending lean. State officials have for requiring Tennesseans to navigate a thicket of paperwork. Prior investigations of TennCare revealed that most people are dropped because of incomplete or unreturned forms. As few as 5% of those dropped are found to be ineligible.

Thirty-five TennCare members challenged its “defective” renewal process in in 2020, and the ongoing case recently added plaintiffs, including the Lesters. The lawsuit accuses TennCare of befuddling its members with vague and contradictory instructions; demanding information it already has or does not need; ignoring the info that members provide; improperly rejecting termination appeals; and, sometimes, sending essential paperwork to addresses that it “knows, or should know,” are wrong.

Michele Johnson, executive director of the nonprofit Tennessee Justice Center, which leads the lawsuit, described TennCare’s renewal process as a “gotcha game.”

“The state’s focus is on trying to find someplace where a family tripped up, rather than on ensuring that the process accurately enrolls families who are eligible,” Johnson said.

The lawsuit asks a federal judge to order TennCare to reenroll about 108,000 people who were dropped in the 12 months before the pandemic emerged and maintain their coverage until and unless the agency can prove they do not qualify.

Waverly Crenshaw Jr., a federal judge in Tennessee, at a March hearing expressed concern about eligible people losing coverage and said termination letters sent by TennCare contain “misleading” language about appealing the decision.

That language has appeared in TennCare letters since at least 2015, including during a period when hundreds of thousands of Tennesseans were cut from its programs, according to TennCare documents obtained by KHN.

“People are falling through the cracks,” the judge said. “And we need something there to catch them before they are swallowed up in the abyss.”

Soon those cracks will widen.

The federal public health emergency is set to expire in October, and Medicaid programs across the country are poised to once again ask families for proof of income. TennCare estimates the renewal process will prune enrollment back to a pre-pandemic level of about 1.4 million members within a year, which means about 300,000 people will leave or be dropped.

Johnson said the looming end of the federal emergency gives the class-action suit “greater importance” even though it is focused on the 108,000 people who were dropped between March 2019 and March 2020.

“We would not expect the state to fix the problems just for the 108,000 and yet leave the defective process in effect for everyone else,” Johnson said.

TennCare officials declined to be interviewed for this story or answer questions about the lawsuit or the appeal information in its termination letters.

In response to emailed questions, agency spokesperson Amy Lawrence said that TennCare is “continually improving the eligibility process” but that members are responsible for keeping their addresses up to date and responding to any renewal paperwork.

When the federal emergency ends, TennCare expects to automatically renew at least half of its members using readily available electronic data, then will send paperwork packets to the rest — as many as 850,000 people — over the next year, Lawrence said.

The Paperwork Purge

TennCare members have been here before. It was messy.

TennCare renewals were paused in 2014 so officials could focus on implementation of the Affordable Care Act. TennCare grew by more than 350,000 people before renewals resumed and many were disenrolled.

A revealed that a sliver of those people were found to be ineligible for TennCare before they were dropped. affirmed this finding: Of more than 242,000 children cut from TennCare from 2016 to mid-2019, only 5% were determined to be ineligible for coverage.

An additional 66% — or about 159,000 kids — lost their insurance because TennCare said their families did not respond to renewal paperwork or provide enough info on that paperwork, according to the audit.

One of those families was the Lesters, who lost their coverage in May 2019. Documents provided by the family and filed in their lawsuit show their packet of TennCare paperwork was first mailed to a house where the Lesters had lived on and off. The packet was returned to TennCare as “undeliverable,” then erroneously re-mailed to a horse pasture next to a relative’s house, then returned to TennCare again.

In other words, the Lesters did not complete the paperwork because they never saw it.

And TennCare knew it.

TennCare also mailed the Lesters’ termination letter to the horse pasture, which is why the family did not realize Mason was uninsured. Lester filed an appeal, but TennCare rejected it as “untimely,” according to a TennCare court filing. Lester filed a new application, but TennCare denied it, the filing states.

In June 2019, Lester gave birth to another son, Memphis, while still trying to convince TennCare they should qualify for Medicaid.

“Hours after having a baby, still doped up in my hospital bed, I was getting in my email, trying to find proof of income to get them everything they needed,” she said.

In 2020, while still uninsured, Lester contracted covid and required hospitalization for two days, she said. The following fall, Memphis stepped on a shard of glass and needed surgery, then soon afterward was hospitalized for a week with covid and respiratory syncytial virus, or RSV, his mother said. Weeks after that, in October 2021, Mason stumbled in the yard and shattered another bone.

This time, hospital staff reenrolled Mason in TennCare in a “presumptive eligibility” category, according to the family’s lawsuit. TennCare covered Mason for about four months before dropping him again.

One month later, in April, the Lesters connected with the Tennessee Justice Center, which finally discovered the clerical error that steered their TennCare paperwork to the horse pasture.

The Lesters joined the center’s lawsuit the following month, and weeks after that TennCare approved coverage for the whole family, saying in a court filing that eligibility was affirmed through the discovery process. The coverage is retroactive to 2019, so it should erase much of the Lesters’ medical debt.

But TennCare defends its initial decision to drop the family, arguing they were “appropriately terminated” for failing to complete renewal paperwork. Kimberly Hagan, the agency’s director of member services, said in a court filing that the Lesters’ problems were “entirely attributable to the failure of the U.S. Postal Service,” which was not delivering mail to the Lesters’ home and gave TennCare an “erroneous forwarding address.”

“While this is an unfortunate set of circumstances, it was not of TennCare’s making and in no way reflects a systemic issue with TennCare’s eligibility reverification and redetermination processes,” Hagan said.

Hagan also said the Lesters could have obtained the lost paperwork by logging in to TennCare’s web portal, TennCare Connect. The portal, part of a , launched about two months before the Lesters’ problems began in 2019.

TennCare Sent ‘Misleading’ Letter for Years

The lawsuit also unearthed concerns that families cut from TennCare may have been misinformed of their right to appeal before an impartial official, also known as a “fair hearing.”

The concerns stem from a paragraph included in some TennCare termination letters. It reads: “If you still think we made a mistake about a fact, you can have a fair hearing. If you don’t think we made a mistake about a fact, you can’t have a fair hearing.”

KHN obtained copies of two TennCare templates for termination letters, dated and , that both contain this language. It was also included in a letter sent to the Lesters.

Crenshaw, the federal judge, said on March 4 that this language “misleads” because people are entitled to a hearing if they believe TennCare made a mistake in “the application of [their] facts to the law.” TennCare has been telling them otherwise, the judge said.

“They don’t lose their right to a hearing. They may be wrong, but … don’t they still have that right to a hearing?” the judge said.

“At a minimum, it frustrates their due process rights,” he added.

An example of a mistake involving “the application of facts to the law” would be TennCare accurately denying someone coverage because their income is too high but failing to consider them for another kind of coverage with a higher income limit.

Johnson, the head of the Tennessee Justice Center, said “many of the mistakes” made by TennCare are like this. In 2019 the agency failed to consider applicants for seven eligibility categories, each of which allows for different income levels, she said.

TennCare denies that its letters were misleading but said in a new court filing that they have been “voluntarily modified” to exclude this language.

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Mike Randol took over May 31 as head of Montana’s Medicaid program, which serves who live in low-income households or have disabilities in a state of 1.1 million people. The program has a roughly $2.3 billion annual budget, with the federal government picking up about 80% of the total.

Randol most recently was an executive with Cerner Corp., which provides health information technology services. Before that, he led Medicaid programs in Kansas and Iowa, both of which hired national management firms to administer benefits, instead of having state employees do it.

“I’m a firm believer in managed care,” Randol told reporters in 2019 as he defended the Iowa program at a news conference announcing an 8.6% annual increase in the rate the state would pay its two management companies.

Montana health department spokesperson Jon Ebelt declined to say whether Randol’s hiring signals that Montana plans to privatize management of its Medicaid programs.

Adam Meier, director of the Montana Department of Public Health and Human Services, said in a statement that he looks forward to working with Randol to better serve Montana Medicaid recipients. “Mike is a proven leader with vast experience in overseeing state Medicaid programs,” Meier said.

The health department declined requests to interview Meier and Randol. Ebelt declined to provide copies of Randol’s application for the job, saying the documents are confidential.

Managed care got a bad reputation in Montana after to manage Medicaid-covered mental health care in the 1990s. The state eventually took back management after numerous patient and provider complaints and after the company, Magellan Behavioral Health, cut provider rates to make up for the loss of millions of dollars in its first year. In 2011, widespread opposition led the state to scrap plans for a managed-Medicaid .

Under managed Medicaid, the state and federal governments pay insurance companies a set amount of money per enrollee to cover health care services. If the companies can do so for less money than they are paid, they pocket some of the difference as profit. All but 11 states, including Montana, have privatized at least part of their Medicaid programs, .

Randol became the Medicaid director in Kansas in 2012, the year before it . Those who backed the change said privatization helped control costs, while critics said it reduced program coverage and transparency.

Iowa Gov. Kim Reynolds, a Republican, hired Randol in 2017. His arrival in Des Moines came about two years after Iowa switched to a private Medicaid management system, which was plagued by complaints that Iowans with disabilities had been and that the management companies lost in the initial years.

When Randol resigned in 2020, Reynolds praised his service: “I am so thankful for the work he’s done to not only stabilize the program, but improve the system, incorporate technology, and set a foundation that we can build on moving forward.”

Deb McMahon, an Iowan who became a vocal critic of Medicaid privatization because of her family’s experience with it, said that if she lived in Montana, she would view Randol’s hiring as a sign the state intends to outsource its program to management companies. “His record speaks for him,” she said.

Vulnerable Montana residents who rely on Medicaid could see major disruptions if the system is privatized, McMahon said. “Their services, the people they count on to help them — all that will change,” she said.

McMahon said that when Randol was in Iowa, he was fond of citing statistics and talking about algorithms. But, she said, he seemed to become irritated when members of the public described how Medicaid changes affected people.

McMahon’s 41-year-old daughter, Annie Stender, has an intellectual disability and uses Medicaid-financed services. Before Iowa’s Medicaid system was privatized, Stender had the same case manager for 15 years, McMahon said. That person knew her well and helped her navigate the array of services.

But under private Medicaid management, Stender has been assigned to several case managers. “We lost that bond,” McMahon said. “We lost that person in our lives.”

, executive director of the Behavioral Health Alliance of Montana, said that Randol’s past in Kansas and Iowa “doesn’t really give us a warm, fuzzy feeling.”

Windecker said she worries a managed-care comeback would lead to lower reimbursement rates for medical providers. She said she’d be surprised if Montana doesn’t consider some form of privatization, in part because of how many other states have done so. “What we’re hoping is, regardless of the model that the state looks at, the providers will be at the table,” Windecker said.

Randol is arriving ahead of a massive review of Medicaid enrollees’ eligibility for the program. Enrollment has increased steadily since the pandemic began, and the federal public health emergency imposed during the covid-19 pandemic has paused routine reviews. When the emergency order ends, certain Montana beneficiaries will likely experience to keep their coverage into the future.

Health advocates have said people who meet coverage requirements could unintentionally be dropped in the process.

Heather O’Loughlin, co-director of the , said that as new leadership takes over, she hopes the priority will be helping people maintain access to their coverage. “This is not a time for political ideology, but an opportunity to listen to health care providers, tribal leaders, rural residents, and those facing barriers in health care to ensure this transition is as smooth as possible,” O’Loughlin said in a statement.

State legislators also are in Montana in response to a shortage of providers and services, beginning with the mental health system. Health providers have long said Medicaid reimbursements fall well below the cost of operating. A program-wide review is expected to take years.

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The 28-year-old mother of four from Salem, Missouri, is among the tens of thousands of uninsured Missourians stuck waiting as the state slogs through a flood of applications for the state-federal health insurance program. Missouri expanded the program last year after a lengthy legal and political battle, and it now covers adults who earn up to 138% of the federal poverty level — about $18,800 annually for an individual.

Missouri had nearly 72,000 pending Medicaid applications at the end of February and was averaging 119 days to process one, more than twice the maximum turnaround time of 45 days allowed by federal rules. Adding people to Medicaid is labor-intensive, and the jobs require training and expertise. The program covers many populations — children, people with disabilities, seniors, adults who are pregnant or have children, and some without children. Different rules dictate who qualifies.

Missouri simply doesn’t have the workers to keep up. Last fiscal year, 20% of its employees who handled Medicaid applications left their jobs, said Heather Dolce, a spokesperson for the Missouri Department of Social Services. And the average number of job applications received for each opening in the department’s Family Support Division — which oversees enrollment — dropped from 47 in March 2021 to 10 in February 2022.

Just about every industry is struggling to find workers now, but staffing shortages in state Medicaid agencies around the country come at a challenging time. States will soon need to review the eligibility of tens of millions of people enrolled in the program nationwide — a herculean effort that will kick off once President Joe Biden’s administration lets the covid-19 public health emergency declaration expire. If Missouri’s lengthy application backlogs are any indication, the nation is on course for a mass-scale disruption in people’s benefits — even for those who still qualify for the insurance.

“If you don’t have people actually processing the cases and answering the phone, it doesn’t matter what policies you have in place,” said , director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C.

Federal officials have said they will give states 60 days’ notice before ending the public health emergency, so it’s unlikely to expire before summer. Once it does, enrollees won’t be kicked off immediately: States can take up to 14 months to complete renewals, although budget pressures may push many to move faster. A bump in federal Medicaid funds to states, provided by Congress through covid relief legislation in 2020, will end shortly after the emergency’s expiration.

Ultimately, workers are needed to answer questions, process information confirming someone’s Medicaid enrollment should be renewed, or see whether the person qualifies for a different health coverage program — all before the benefits lapse and they become uninsured.

State Medicaid officials have said staffing is one of the top challenges they face. In a January meeting of the Medicaid and CHIP Payment and Access Commission, an outside panel of experts that advises Congress, Jeff Nelson said 15% to 20% of the Utah Department of Health’s eligibility workers were new. “We’ve got a fifth of the workforce that potentially doesn’t know what they’re doing,” said Nelson, who oversees eligibility for Utah’s Medicaid program.

Eligibility worker vacancies at the Texas Health and Human Services Commission quadrupled over roughly two years — 1,031 open positions as of late February compared with 260 as of March 31, 2020, according to spokesperson Kelli Weldon.

Medicaid renewals are less labor-intensive than initial applications, but it takes time before an eligibility worker knows the ins and outs of the program, Wagner said.

“It’s months before you are fully functional,” said Wagner, who previously oversaw the Illinois Department of Human Services’ offices that determine applicants’ eligibility for Medicaid, the Supplemental Nutrition Assistance Program that provides food stamps, and other assistance programs.

Other social services may be gummed up in the process because many workers also handle applications for other programs. In addition to Medicaid, workers for Kentucky’s Department for Community Based Services handle SNAP and child care assistance applications.

Consumer advocates who connect people to safety-net programs worry that an overwhelmed workforce won’t be able to keep up.

“It’s going to be a lot of work for everyone,” said Miranda Brown, who helps people apply for benefits as outreach coordinator for the , a legal aid group.

Brown said she recently called a state office on behalf of a client toward the end of the day. She waited on hold for an hour only to be told by a caseworker that the agency couldn’t process any more cases that day.

“I even have a [phone] line that I get through faster than a consumer calling for themselves,” she said. “If it’s hard for me, it’s very hard for consumers who are trying to call on their lunch break at work.”

South Carolina planned to hire “a couple hundred workers” beginning this spring to help manage renewals at the end of the public health emergency, said Nicole Mitchell Threatt, deputy director of eligibility, enrollment, and member services at the Department of Health and Human Services. The turnover rate among eligibility workers was about 25% from July 2020 to June 2021, jumping from a 15% rate in the previous 12 months.

In Missouri, Dolce said her department hopes a recently approved pay increase will help recruit more workers and improve staff morale and retention. The department is being over delays in enrollments for SNAP benefits, which it also oversees.

Kim Evans, director of the Missouri Department of Social Services’ Family Support Division, told the state Medicaid oversight committee in February that her division was offering overtime and she was even offering to buy pizza to speed up the processing of applications. But the department is enrolling fewer than 3,000 people per week, leaving tens of thousands waiting and delaying their care.

In the suburbs of Kansas City, Missouri, Stacey Whitford, 41, applied in December for Medicaid for herself and her 13-year-old son. Her son needs hearing aids that she said cost $2,500 apiece without insurance. She also lined up a support worker for the boy, who has autism, through the Department of Mental Health but said she was told the worker can begin only once her son is enrolled in Medicaid.

“It’s just like hanging a golden ticket right in front of your face and saying, ‘Here it is, but you can’t touch it,’” she said in early March.

Whitford spent hours on the phone trying to sort out the status of their applications, then on March 31, just shy of four months after applying, they were finally approved.

“I am so excited! We can run with scissors now,” she joked.

But Elliott, the mother of four in Salem, is still waiting. She gave up calling the state’s Medicaid helpline after growing frustrated from spending hours on hold and being disconnected because of high call volumes. Instead, she checks on her application through the enrollment specialists at the clinic where she applied.

She was sent home from the ER with ibuprofen and Tamiflu and has yet to see a bill. If her Medicaid application is approved, her coverage will be backdated to the month she applied, likely covering her ER trip. But if her application is rejected, that cost will be added to her medical debt, which Elliott estimates is already tens of thousands of dollars.

“It makes me feel like it’s a joke,” Elliott said of Missouri’s expansion of Medicaid. “Like they’re just throwing it out there to get all these people to apply for it, but they’re not going to really help anybody.”

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Trinity Health, a national Catholic tax-exempt chain, wants to close Mercy Hospital and Medical Center on Chicago’s Near South Side by May 31. Last month, in an unusual move, the Illinois Health Facilities & Services Review Board Trinity permission to close the 412-bed facility, which predominantly serves Black and other minority patients on Medicaid.

The board members said they feared the closure would limit access to care for nearly 60,000 South Side residents, forcing them to travel nearly 7 miles to the closest facility with an emergency room, intensive care unit and birthing center. It also would cost the community about 2,000 hospital jobs.

Urban hospitals in low-income areas of , , , , and other cities and suburbs face similar financial squeezes. Inner-city facilities like Mercy struggle to survive on lean payment rates from Medicaid and to compete with .

So far, no one has come up with a politically and financially viable solution for strengthening safety-net health providers in low-income urban communities. “The sad fact is market location is everything,” said Lawton Robert Burns, a professor of health care management at the University of Pennsylvania, who studied in Philadelphia in 2019. “No offense to poor people, but there are economic factors that hospitals can’t control.”

But it is far from clear that a government board can stop a hospital from going out of business. “It’s really difficult in a capitalist country to tell a private company you have to continue to lose money,” said Dr. Linda Rae Murray, a member of the health facilities board and former Trinity Health board member who teaches health policy at the University of Illinois-Chicago.

, which operates 92 hospitals in 22 states, seems determined to push forward with its plans to close the hospital. It has deep pockets, with $31.9 billion in total assets. It reported revenue of $18.8 billion last year, and a profit of 2.3% in the most recent quarter. Trinity executives told the health facilities board in December that Mercy loses nearly $39 million a year and that they could not find any buyers for the hospital — Chicago’s oldest, chartered in 1852. They also reminded the board that to merge with three other South Side hospitals and build a new hospital facility and several new clinics with $520 million in state aid.

Trinity declined to make anyone available for an interview for this article.

Trinity has said it will try again to get approval to shut Mercy at the facilities review board’s Jan. 26 meeting. It has offered to replace the hospital with a $13 million clinic offering just diagnostic and urgent care — but no primary care physician services. Critics of that proposal say the clinic, while helpful, would not be an adequate replacement for the hospital because it would not provide access to the full range of needed services.

“We can’t have these mega-hospital companies that are getting a property tax exemption for providing charity care closing a safety-net hospital in the middle of a pandemic,” said former Illinois Gov. Pat Quinn, a Democrat who spearheaded a , another embattled facility on Chicago’s South Side. “I’d tell the Trinity executives, ‘You’re not doing this to Chicago. We’ll work with you to put together a bigger deal.’”

The obvious long-term solution is for safety-net hospitals, effective partnerships between public and private providers and firm commitments by financially strong hospital companies, including academic medical centers, to expand services in low-income communities. For instance, some say state and local officials should prod Trinity to use the resources of its Loyola University Medical Center in west suburban Chicago to bolster Mercy.

Hospitals are required to get a certificate of need for closure from the facilities review board, according to a . But state officials’ actions are limited when seeking to enforce a decision to keep a facility open.

The state could levy a fine of up to $10,000 for not complying with the board’s decision, plus an additional $10,000 a month while the hospital continues to operate. But that’s a trivial amount for a big company like Trinity.

The state also could halt Medicaid and other public payments to Mercy. But that would be counterproductive, hastening the hospital’s demise since nearly half of Mercy’s inpatient revenue and 35% of its outpatient revenue comes from Medicaid, according to state data.

A final source of leverage is in Trinity’s ownership of three other hospitals in the Chicago area: Loyola, Gottlieb Memorial Hospital and MacNeal Hospital. The state could threaten Trinity’s property-tax exemption as a charitable organization. That’s an approach favored by Quinn, who cited a to the tax-exempt status of the Carle Foundation Hospital in Urbana, Illinois.

No matter what the state does, Trinity can find ways to shut down Mercy. It could argue that even as Mercy is meeting the state requirement to continue to treat patients, it must close critical services like the emergency department or the birthing center because it lacks funding or staff to maintain adequate quality of care, said Juan Morado Jr., a Chicago health care lawyer who formerly served as general counsel for the facilities review board. The new law permits closing only one hospital department every six months.

While the state presses to keep the hospital open, Mercy also could suffer from attrition. When there’s talk of closing a hospital, physicians, nurses and other staffers may start leaving for other jobs. Whether Trinity seeks to refill positions is critical.

“There are things the owner can do to trickle the hospital down to nothing,” said Dr. David Ansell, senior vice president for community health equity at Rush University Medical Center in Chicago, who opposes shuttering Mercy. “There is a drip, drip, drip of negativity, and at some point people vote with their feet.”

The Chicago area has been through a similar battle recently. Pipeline Health, a private-equity investment firm, bought Westlake Hospital in suburban Melrose Park and two other local hospitals from hospital chain Tenet Healthcare in 2019. Pipeline it was closing Westlake, a 230-bed hospital — even though it had promised the state it would keep it open for at least two years.

That controversial move prompted the Illinois legislature to give the facilities review board new authority to deny permission for future hospital closures, which the board lacked for Westlake.

Yet, the Westlake saga may point to a better solution for Mercy. In early 2020, the state and federal governments renovated the Westlake facility so it could be used as an overflow site for covid-19 patients. It wasn’t needed, but the updates led to strong interest from companies in purchasing and reopening the hospital, particularly for behavioral health inpatient services.

State Rep. Kathleen Willis, a Democrat who co-sponsored the 2019 bill to let the facilities review board say no to hospital closures, said a deal to buy and reopen Westlake likely will be announced within the next few weeks.

Any deal to save Mercy likely will require more money from Trinity, more commitment from other providers to offer a full range of hospital and medical services in the area, and significant increases in state and federal funding.

“Every hospital CEO has to worry about the bottom line of their business,” Ansell said. “But big organizations like Trinity need to come up with a better solution than the wholesale shutdown of an anchor institution that will leave communities bereft.”

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