Given that we are in the middle of the implementation of the Affordable Care Act (ACA), and a full verdict on what is happening will not really be known for a short while, it is a prudent idea to wait before making definitive comments on what is happening out in the field.  The reality is that the "data" on the implementation of the ACA is still coming in, and none of us can be 100% sure at this point what is happening.  

However, a commentary by Patrick Ishmael (of Missouri's Show-Me Institute) in Forbes deserves a response.

For full disclosure, I serve as Chair of Missouri's MOHealthNET Oversight Committee, a public body that has the duty of overseeing the state's Medicaid program. We meet about four times a year.  By statute, the members of the committee are recommended by the Governor, and vetted by a state Senate committee.  The committee is widely representative of health constituencies in the state: health providers, professional groups, consumers, four Legislators, and heads of state agencies.

In Ishmael's article he makes a few points related to Missouri:  that the expected increase in Medicaid enrollment is not happening, that in fact Medicaid enrollment is falling, that there is a backlog of potential enrollees who have not been processed (mostly from the federal government's website) and that even those potential enrollees may not be "real" because of flaws in the data.  He concludes therefore that Missouri's Medicaid program is "getting smaller" through a combination of administrative incompetence as well as statewide resistance.  He then adds that all this is happening to a Medicaid program that is in fact a "broken program."

This all sounds very dire, and sounds like an indictment of the ACA.  But the reality is that the story behind this is much more nuanced, and it is not what Ishmael is telling us in his piece.  Here are some fundamental facts that must be considered when sorting through this:
  • for years Missouri has had a very old and antiquated enrollment system based on out-of-date software.  The state allocated some funds, and received some federal funds to bring this enrollment system up to date, and this is being implemented now (fully live as of January 2014) for a portion of the currently-eligible Medicaid population;
  • the new enrollment system takes account of new federal rules for enrollment in Medicaid that take effect regardless of the states decision not to expand Medicaid, so even though the state did not expand Medicaid, it was important for the state to make these changes;
  • at the same time as all of these important administrative procedures were being implemented, the state has suffered from cutbacks in staff, which is the result of budget cuts implemented by the Governor and Legislature;
  • the agency that implements Medicaid has gone through a significant reorganization in recent months, and also important transitions in leadership;
  • Missouri's policymakers have decided not to implement a Medicaid expansion to date, which has left a significant share of the state's population in a "gap" group without coverage;
  • Missouri's policymakers (and voters) have made the decision to not opt for a state-based marketplace, thus the state has been forced to use the federal marketplace, which had a very flawed start for about six weeks.  
  • In addition, there perhaps has been no other state in the country that has been so openly resistant to implementing the ACA, as reflected in resolutions passed by the Legislature, and by the voters.
The last points are important because while Ishmael seems to want to blame the issues in Missouri on administrative "incompetence" he conveniently does not tell the readers that in fact in Missouri the state workers charged with implementing the federal law of the land have faced resistance at every turn.  

In fact this is one place where I agree with Ishmael, as he says in his article "statewide resistance" is a big part of the problem here. What Ishmael conveniently does not say is that the resistance has come from places like the Show-Me Institute, the majority in the Legislature, and others.  This organized and fierce opposition to "Obamacare" has surely made it more difficult to implement the law.  When this problem is added to all of the other complexities listed above, it is obvious that the state's Medicaid agency has faced a firestorm of issues, all coming at the same time.  So in reality, much of this has been self-inflicted, but not from the Medicaid agency itself, but from the policymakers charged with setting the policy and budgets governing Medicaid, and from their supporters.

Another important point that Ishmael glosses over is: why have medicaid enrollments been dropping?  In fact, a longer look at Medicaid enrollment in the state over time shows that Medicaid enrollments rise when the economy suffers, and falls when the economy improves. This author has completed analysis correlating Medicaid enrollment in the state of Missouri with unemployment rates, and finds that the decline in unemployment may explain some if not a good deal of the recent drop in Medicaid enrollment.  Certainly a good fiscal conservative would be happy to see public coverage drop as the economy improves.

Now does all this lead one to conclude there are no issues of concern?  No. The backlog of potential enrollees that appear to be sitting in the offices in Jefferson City are a real concern.  if indeed these represent real individuals who need to be on Medicaid by law, then it is imperative that these individuals be enrolled as soon as possible.  If there are issues with their data that came from the federal government, that is indeed a concern, but I hope that MOHealthNET is making this a top priority to solve this issue.  I do believe they are.

But what I do not believe is what Ishmael believes -- that most of these individuals are not entitled to Medicaid enrollment, that there is no woodwork effect.  I do agree with him on one thing: statewide resistance to the ACA is a big contributor to this problem.  If Patrick Ishmael wants to agree to work on lowering that resistance, so that the law of the land can be implemented, and so that low income individuals who have a genuine need of health coverage through the safety net can be covered, then we have a strong agreement there.  And I hope everyone can work with state officials to resolve these issues.

Timothy McBride, PhD
Chair, MOHealthNET Oversight Committee, Missouri