Missouri must fix Medicaid’s paperwork problem before work requirements begin​​​​​​​​​​​​​​​​

A proposal to write work requirements into the state constitution passed the Republican-led House this year but stalled in the Republican-led Senate, expiring without a vote when the session adjourned. The federal mandate is coming either way. 

The question is whether Missouri can administer it without stripping coverage from people who remain eligible. Its recent record says no.

The consequences are already visible among people whose eligibility rules haven’t changed at all.Enrollment among Missouri children has fallen by more than 178,000 since March 2023, even though income eligibility rules for children haven’t changed.

Processing times tell a similar story. In February 2024, 72% of Medicaid applications took longer than the federally required 45 days to process. Missouri brought that down to about 15 days by late 2025, real progress. By February this year, roughly a third of applications were again taking more than 45 days, compared to 7% nationally. 

The state has proven it can fix this problem. It has not proven it can sustain it.

The most recent completed renewal cycle shows the scale of the problem before any new rules take effect. Of the Missourians whose Medicaid eligibility came up for renewal over one recent year, only 54% were successfully renewed. Twenty-eight percent were disenrolled. Eighteen percent were left pending, their cases unresolved months later.

Some of those failures happen even when people do everything right. Joel Ferber, director of advocacy at Legal Services of Eastern Missouri, said the department’s computer system will sometimes automatically terminate a person’s coverage if staff don’t begin processing paperwork within 30 days — regardless of whether that paperwork was complete and on time. 

“We have all these clients that send in all their paperwork, and it doesn’t get processed,” Ferber said, “but the system closes the case.”

Missouri’s own budget requests show a department that knows how far behind it is. Social Services Director Jess Bax called the federal timeline “extremely aggressive.” The state has asked lawmakers for hundreds of millions of dollars, more than 200 additional staff for ongoing implementation, and contract workers to clear a backlog of 90,000 pending renewals that predates the work requirement. Missouri also risks losing up to $1.2 billion starting in 2029 if its Medicaid error rate climbs above 3%, a threshold that grows harder to meet as pandemic-era standards are tightened.

Every wrongful termination adds to the state’s administrative burden: appeals, case reopenings and repeated eligibility determinations. Those are costs Missouri would incur while also trying to avoid up to $1.2 billion in federal funding losses tied to high error rates.

The state also plans to use artificial intelligence to help verify compliance. 

“Missouri has been kind of behind the curve on most technology,” said Elias Tsapelas of the libertarian-leaning Show-Me Institute, noting the state’s computer systems often can’t communicate with one another. 

The department says a human will review every case before coverage is terminated. But researchers who study automation bias have found for decades that reviewers tend to defer to a machine’s recommendation rather than independently check it. Human review is a safeguard, not a guarantee.

Missouri would not be the first state to find out the hard way. Arkansas became the first to impose Medicaid work requirements in 2018. Within seven months, more than 18,000 people, roughly 1 in 4 of those subject to the rule, lost coverage. A federal judge blocked the policy the following spring. Research from Harvard found it did not increase employment at all. 

“The idea of work requirements is to get people into new jobs and private insurance,” said Benjamin Sommers, the study’s lead author. “But in our study that didn’t happen.” The losses fell largely on people who couldn’t navigate the reporting system, not on people refusing to work, hitting hardest among those without home internet access, since Arkansas required enrollees to report online. Missouri ranks 30th nationally for broadband access, a vulnerability its own rollout will inherit.

Missouri has told lawmakers what it needs. If the state cannot meet that standard in time, the law it is implementing already accounts for that: states can request a delay of up to six months at a time, through the end of 2028, by showing good faith effort to comply. Missouri does not need a new watchdog. The state auditor’s office has already audited Medicaid eligibility determinations and found problems before. That office is independent of the agency it would be checking. Lawmakers should put it to use now, as an early warning system, not a review that happens only after people have already lost coverage.

Missouri has less than five months before federal work requirements begin. Can Missouri distinguish between someone who failed to meet the requirement and someone who met every requirement but was failed by the state’s own paperwork? 

Before Missouri asks hundreds of thousands of people to prove they qualify under a more complicated system, lawmakers should make sure the state can accurately process the paperwork it already receives. Eligibility, not administrative error, should determine who keeps health coverage.