Faxes and Postal Mail: Will Pandemic-Era Flaws Trigger Improved Health Technology?
Jamie Taylor received two letters from the Family Support Division of the Missouri Department of Human Services that began with “Good news”, before stating that she had been denied Medicaid coverage. His income exceeded the state limits for the federal-state public health insurance program for low-income people.
Missouri officials are now blaming the incongruous greeting for the bad news decidedly on a computer programming error, but that was just the start of the ongoing saga of Taylor trying to enlist help from the Missouri safety net. Taylor, now 41, spent hours on the phone, enduring four-hour wait times and dropped calls, and received delayed shipments of urgent documents to her home in Sikeston.
Taylor’s struggles are not uncommon in Missouri or even nationally. Instead, they are part of what National Association of State Medicaid Directors Executive Director Matt Salo called “the next big challenge for government to solve.” Namely: the extremely outdated technology used by a vast network of government agencies, from local public health to state-run employee benefit programs.
Although many people like Taylor struggled with these systems before the pandemic began, covid-19 revealed how outdated and ill-equipped many of them were to handle unprecedented demand. For example, while private sector companies were building capacity to stream TV shows, building apps for food deliveries and moving offices online, public health officials were tracking covid outbreaks by fax.
In response to the new light shedding on these long-standing issues, momentum is building for government technology updates. The pandemic has also created once-in-a-generation cash reserves from pandemic relief funding and higher-than-expected tax revenues to fund such projects.
President Joe Biden issued an executive order in December calling for the streamlining of benefits enrollment. State lawmakers are urging the use of unspent covid relief money to address the problem.
This is critical because outdated information systems can trigger ripple effects throughout the public benefit system, according to Jessica Kahn, who is a partner at consulting firm McKinsey & Co. and previously led the data and systems for Medicaid at the Centers for Medicare & Medicaid Services. An example: Online benefits applications that are not user-friendly may lead more applicants to call the helplines. This can put a strain on call centers which, like many industries, struggle to meet staffing needs.
Some states are already considering improvements:
- In Wisconsin, Democratic Gov. Tony Evers has directed up to $80 million to replace the state’s outdated unemployment infrastructure.
- Kansas is one of the first states to work with the US Department of Labor’s new Office of Unemployment Insurance Modernization, which is expected to manage $2 billion in funds allocated by the American Rescue Plan Act last year. .
- In Missouri, a bipartisan state Senate committee has recommended using excess covid relief funds for the Department of Human Services to update benefit computer systems. The department also proposed using federal pandemic money on artificial intelligence to process some 50,000 documents a week. This work is currently done manually at an average of two minutes per document.
Recent history suggests that these fixes may be easier said than done. More than 10 years ago, the Obama administration invested $36 billion to expand and mandate the nationwide use of electronic health records for patients. Despite the billions invested, the digitization of patient records is plagued with problems. Indeed, to be reimbursed by their insurers for purchases of rapid covid tests, a requirement imposed by the Biden administration, patients must fax or mail claims and receipts.
The Affordable Care Act also offered a chance to improve the state’s technology infrastructure, according to Salo. From 2011 to 2018, the federal government offered to cover up to 90 percent of the funds needed to replace or update older Medicaid computer systems, many of which were programmed in COBOL, a computer programming language dating back to 1959. Updates that could have benefited others are also part of the government’s safety net, since state-run assistance programs frequently share technology and personnel.
But, Salo said, the ACA required that these new Medicaid computer systems communicate directly with the health care exchanges created under the law. States faced varying degrees of difficulty. Tennessee’s bids were lost, leading to a class action lawsuit. Many states have never fully overhauled their benefit systems.
During the pandemic, technological issues have become impossible to ignore. Amid early lockdowns, hundreds of thousands of people waited months for unemployment assistance as states such as New Jersey, Kansas and Wisconsin struggled to program newly created benefits into existing software . Local and state vaccine registration sites were plagued with so many problems that they were inaccessible to many, including the blind, a violation of federal disability laws.
Underfunding is nothing new in public health and safety net programs. Public officials have been reluctant to allocate the funds needed to overhaul outdated computer systems – projects that can cost tens of millions of dollars.
The woes of Missouri’s backstop technology are well documented. A 2019 McKinsey assessment of the state’s Medicaid program noted that the system was made up of about 70 components, partially developed in a 1979 mainframe computer, which was “not positioned to meet current and future needs.” In a 2020 report for the state, Department of Human Services staffers called the benefits enrollment process “siloed” and “built on workarounds,” while participants described as “dehumanizing”.
Taylor experienced this frustration. Eight years ago, a mysterious medical condition forced her out of the workforce, causing her to lose her job-based health insurance. She was repeatedly diagnosed with ulcerative colitis, Crohn’s disease, gastritis, inflammatory bowel disease and gastroparesis, but lacking insurance and unable to qualify for Medicaid, she was forced to get treatment in the emergency room. She has been hospitalized several times over the years, including a combined 21 days since July. She estimated her medical debt was $100,000.
When Taylor applied for Medicaid again by phone in October, she received a denial letter within days.
At a loss because her family of three’s monthly income of $1,300 now falls within state income limits since Missouri’s Medicaid expansion in 2021, Taylor contacted state Representative Sarah Unsicker . The Democratic lawmaker represents a district 145 miles away in St. Louis, but Taylor had seen her championing Medicaid expansion on Twitter. After Unsicker questioned the department, she learned that a default answer had disqualified Taylor from getting Medicaid because it incorrectly listed her as receiving Medicare — the public insurance designed for older Americans to which Taylor is ineligible.
“Within 24 hours I got a message from Sarah saying another letter was on the way and I should be much happier with the response,” Taylor recalled.
Finally enrolled in Medicaid, Taylor is now struggling to get nutritional assistance, called SNAP, which in Missouri is processed through a separate eligibility system. The programs have similar income requirements, but Taylor was unable to verify her income over the phone for SNAP like she could for Medicaid.
Instead, she received a letter on November 26 asking for her tax returns by November 29. By the time she was able to locate and email those documents on December 1, she had been turned down. Every call to fix the problem has been met with wait times of over four hours or queues so full that his call is dropped.
Medicaid and SNAP apps are combined in 31 states, according to a 2019 analysis by advocacy group Code for America. But not in his.
“It just doesn’t make sense to me that Medicaid can verify my tax income over the phone, but SNAP needs me to send them a copy of the package,” Taylor said.
Eventually, she gave up and started the whole process again. She is still waiting.