Parents asking for partially full insulin pens so they can cover the cost with cash. Lapsed prescriptions for asthma inhalers. New moms foregoing doctors’ appointments for newborns. Young children missing vaccinations, making them vulnerable to otherwise preventable diseases. Inability to secure life-saving residential treatment for eating disorders and mental illness.
These are just some of the consequences pediatric health care providers across the state have seen as a result of children losing health insurance during the Medicaid redetermination process.
Fewer kids were covered by Medicaid by the end of December 2023 than before the pandemic, according to a report released this week from the Georgetown University Center for Children and Families. Montana’s 15% decline represents the largest drop in that time frame in the country.
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The report’s authors said that this figure is likely an undercount of the impact because it fails to capture the number of children who experienced a lapsed in coverage or those who shifted over to Healthy Montana Kids, the no-cost insurance program available to young people from households with incomes over the Medicaid limit.
Joan Alker, the executive director of Georgetown’s Center for Children and Families, called the trend “troubling” and said “there are many, many reasons to worry.”
Medicaid is a joint program between state and federal governments. While the state administers the program, it’s heavily subsidized with federal dollars. Over the last eight years, Montana has averaged spending 13% of its general fund budget on Medicaid, one of the lowest rates in the country.
To qualify for the program, Montanans must meet several requirements to show they are in need of health care assistance as well as be low-income. For example, a household of four cannot earn more than $31,200 before taxes to be eligible for traditional Medicaid.
The Legislature voted in 2015 to expand Medicaid to more nonelderly adults, raising the income limit to $43,056 for a household of four to be eligible for coverage under Medicaid expansion. It renewed the expansion program in 2019. Anyone under the age of 19 in a household of four earning $78,000 or less would be eligible for Healthy Montana Kids.
Erin Green is a general pediatrician at a private practice in Helena. About 40% of the clinic’s patient population was covered by Medicaid before redetermination. She’s seen parents who have lost their insurance waiting longer to seek treatment for their kids. What could be fairly minor illnesses become bigger problems that land them in the emergency department.
“Medicaid unwinding is preventing preventative care,” Green said. “That is what we’ve seen.”
Starting in April 2023, Montana, like all other states, began the process of redetermining eligibility for Medicaid after enrollees had been automatically enrolled during the pandemic-era health emergency.
Enrollment in Montana climbed to its highest recorded levels — more than 300,000 — during the three-year COVID-19 window. More than 130,000 have lost coverage for at least some amount of time since redetermination began, a majority due to technical errors and not ineligibility.
Total enrollment was back at pre-pandemic levels as of January 2024, according to data provided by the Department of Public Health and Human Services, but still well below pandemic highs. An analysis from the Montana Healthcare Foundation concluded that increased Medicaid coverage led to better access to preventative care and fewer trips to the emergency room.
DPHHS cautions people against coming to conclusions until the process is fully complete, spokesperson Jon Ebelt said in an email. The health department did not provide data broken out by age or demographic to illustrate the most up-to-date population-specific impacts of redetermination.
“This process has meant ensuring the most vulnerable have access to the resources they need while also protecting taxpayer resources from intentional or unintentional program abuse,” Ebelt said.
A separate report from the Urban Institute found that as of November 2023, Montana had one of highest rates of disenrollment of children in the country, and that it had exceeded the think tank’s projections by 180%. The analysis also concluded that Montana had one of the largest gaps between the rate of disenrollment among children and adults, the former far outpacing the latter.
With a 27% drop in Medicaid enrollment among children between April and December 2023, Montana has seen the second-steepest decline in the country. Lauren Wilson is a pediatric hospitalist in Missoula, and she says the impact of lost insurance coverage is only starting to be realized among patients.
Well exams are critical for kids to receive screenings for conditions like scoliosis, developmental milestones and mental health conditions such as anxiety or attention deficit disorder. These appointments are also the time when young children receive immunizations for conditions such as measles and are monitored for early signs of autism or diabetes, for example.
“I don’t have to speculate,” she said. “When children are uninsured, their health outcomes are worse. We know that when children aren’t insured they have a harder time managing illnesses, and they are more likely to be hospitalized.”
Wilson said she first started noticing the toll redetermination was having on children last summer. The federal government sent DPHHS a letter in August voicing concerns over the state’s process and its disproportionate impact on kids, but Wilson says she’s still seeing families in her hospital every week who are without coverage or are currently trying to prove eligibility.
States who saw children lose coverage at a lower rate took specific steps to protect them against disenrollment, the Urban Institute found.
Oregon, for example, established continuous eligibility for young children through age 6. Others paused redetermination among youth populations or took advantage of federal waivers to allow automatic renewals without action on the part of families based on participation in other government programs.
DPHHS conducted a five-month public awareness campaign last year primarily focused on radio and digital marketing to get the word out about re-applying for Medicaid, according to Ebelt. He said the agency sent out approximately 100,000 text messages to households it deemed most likely to have new mailing addresses to encourage them to update their information.
Any Montanan who believes they are eligible for Medicaid can apply at any time here. If someone lost Medicaid but is able to prove eligibility within 90 days, they can have retroactive coverage for up to three months.
Looking ahead, Montana Medicaid will return to its annual redetermination process.