If they knew they didn’t have to, would anyone do paperwork?

Over the past few months, I’ve talked a lot about Missouri resuming its Medicaid eligibility redetermination process. In short, during a three-year pause on eligibility checks, Missouri experienced enormous Medicaid enrollment and cost growth. Today, more than 20% of all enrollees are likely ineligible for the program, either because they make too much money, have coverage from their employer, or have moved out of state. This means that Missouri is wasting upwards of $120 million each month footing the bill for health coverage for people who aren’t qualified to receive it.

Missouri’s Medicaid agency is now two months into processing redeterminations and enrollment has finally started dropping, albeit slowly. Recent reports from both national and local news outlets are attributing the enrollment decline to “paperwork issues.” In my opinion, this characterization is incredibly misleading.

States classify anyone who fails to respond to a renewal application as being removed from the program for “procedure reasons.” This is being referred to as “paperwork issues” by some. This is in contrast to the other classification of individuals removed from the program—those who were “determined ineligible.” The problem is that if the state never hears back from an enrollee after repeated attempts to confirm their eligibility, they can only be removed from the program for “procedure reasons” because there wasn’t enough information to determine their eligibility one way or another. Calling all failures to respond to the state Medicaid eligibility checks “paperwork issues” misses a key point.

Someone who knows they no longer qualify for coverage is incredibly unlikely to go through the effort of filling out and returning the Medicaid renewal application. For years, individuals on essentially every welfare program (including Medicaid, Supplemental Nutrition Assistance Program [food stamps], and Temporary Assistance for Needy Families) have been required to inform the state when something changes that would make them ineligible for services, but they rarely do. Recently, the Congressional Budget Office estimated that more than 5 million Medicaid enrollees nationally are currently enrolled in private health coverage, meaning states are losing billions providing coverage to individuals for whom it’s completely unnecessary.

Most Medicaid rules are biased toward recipients maintaining continuous coverage, which may sometimes be a good thing, but for many people, Medicaid is a resource they only need temporarily. No one is saying that eligible Medicaid enrollees should be removed from the program, but even if that does happen, they’re still effectively covered because the federal government will cover up to three prior months of health costs once they’re determined to be eligible again.

Removing Medicaid recipients who don’t provide evidence of eligibility is a necessary act of fiscal prudence—an act of prudence that, prior to three years ago, was standard, federally mandated operating procedure.

There’s no getting around the fact that more state tax dollars being spent on ineligible Medicaid enrollees means less money for other state spending priorities, such as education and infrastructure. If Missouri’s elected officials ever want a chance at reining in Medicaid’s runaway spending, scrutinizing the program’s rolls must remain part of the equation, and occasional drops in enrollment must be normalized as simply par for the course.