For several months now, politicians have been telling two stories about Missouri's Medicaid system.

One version, trumpeted by Democratic lawmakers, tells of a crisis in which thousands of people, the majority of them children, are being kicked off the rolls each month under questionable circumstances. The state could help, they say, but a Republican administration is content to stand by and let the tragedy unfold.

Republicans in the legislature and the Governor's Mansion, on the other hand, tell a sunnier story. Yes, people are coming off the rolls, they say, but there are good reasons: an improving state economy is putting people to work and new technology is powering a much-needed "cleanup" of the rolls to ensure everyone receiving benefits is eligible.

Independently determining exactly who's right and to what degree is difficult. There are no existing plans for public hearings and an obvious method of investigating the issue has its own limitations.

But here’s what we know so far.

Shrinking enrollment

One thing that's not in dispute is that in recent months, a substantial number of people have come off the rolls of Missouri's Medicaid system, called MO HealthNet.

A review of the most recent caseload numbers shows roughly 127,000 fewer people were receiving Medicaid benefits in July than there were in January 2018, a 13 percent drop.

It also shows that about 54,000 of those people dropped from the rolls between the beginning of the year and last month, a roughly 5 percent reduction over that span of time.

The question of why is more divisive.

When Gov. Mike Parson released a Fiscal Year 2020 budget proposal in January calling for reduced Medicaid spending, his budget director attributed the drop to an improving economy, according to the St. Louis Post-Dispatch.

To his credit, the unemployment rate remained low at 3.2 percent and down from 3.5 percent in January 2018.

But a month later, a Kaiser Health News report was raising doubts about that explanation. It noted that Missouri was shedding Medicaid recipients at a rate far faster than other states and pointed out the slide coincided with the introduction of a new approach to verifying recipients’ eligibility.

Timothy McBride, a health economist at Washington University in St. Louis who at the time headed the MO HealthNet oversight committee, suggested in that story and a recent interview with the News-Leader that the retooled system was making renewals too difficult. In some cases, letters sent to people identified as ineligible weren’t reaching them.

State Sen. Scott Sifton, D-Affton, sent a letter to the Department of Social Services that month seeking an explanation.

Patrick Luebbering, director of the department’s Family Support Division, responded in a letter dated Feb. 28 that elaborated on the budget director’s earlier explanation.

In addition to “the improving economy,” Luebbering attributed the drop in caseload to recent changes in the Affordable Care Act and new technology allowing the state “to better track and issue annual reviews.”

He also included an outline of the annual case review process that he noted was required by state and federal law and that included multiple ways the department worked to let individuals know they would be getting a time-sensitive renewal notice.

He acknowledged “there are many reasons why someone might not complete their review” and that low-income Medicaid recipients move more often than the general population and might be homeless, making receiving mail tricky.

He also emphasized that people wanting coverage have to take some initiative, too.

“However,” he wrote, “this does not alleviate our obligation under the law to conduct annual review, nor does it alleviate the personal responsibility of individuals to keep us up to date on their personal information.”

'Needed cleanup'

That message hardly ended the criticism.

At the April meeting of the Medicaid oversight committee, Joel Ferber, the director of advocacy at Legal Services of Eastern Missouri, charged the state with failing to live up to some of its own responsibilities.

For one, he said, the department wasn’t using information submitted for the Supplemental Nutrition Assistance Program, or food stamps, to evaluate Medicaid eligibility like federal regulations require.

Ferber also raised concerns about the issues his organization's clients faced when they sought help from the state filling out their complicated paperwork, describing “dysfunctional call centers" and “the inability of receiving any help from the local FSD offices,” according to meeting minutes.

House Minority Leader Crystal Quade, D-Springfield, reiterated those concerns in a letter to House Speaker Elijah Haahr, R-Springfield, last month calling for investigative hearings.

Haahr has thus far been unmoved.

After getting an update from state Medicaid Director Todd Richardson and Rep. David Wood, a Versailles Republican who chairs the committee that oversees the department’s budget, he repeated that an improving economy and changes to the Affordable Care Act contributed to the decrease in enrollment.

He also threw another issue into the mix in an emailed statement Monday.

From 2014 to 2018, he said, the state failed to “robustly verify eligibility requirements of individuals on an annual basis” and therefore renewed coverage for people who weren’t eligible.

“With new software, the comprehensive review is performing a needed cleanup of those who are not eligible for Medicaid benefits,” he continued.

Haahr also offered a remedy to those who missed their mailers or didn't understand how to fill them out the first time, emphasizing that anyone who loses Medicaid coverage can always reapply at “over 263 entities statewide” and get their benefits back going forward and for the preceding quarter.

In an interview with the News-Leader this week, McBride, the former oversight committee chair, said it was nearly impossible to tell whether Haahr was right at this point.

The best way to tell if people who didn’t return mailed renewal notices remain eligible is to contact them and ask, he said.

“But if the problem is that (the state) is dropping people because they can’t find them, how would they do a survey?” McBride asked.

Ultimately, he said, time and budget numbers may tell. If thousands of people heed Haahr’s advice and get signed back up, he reasoned, the state’s budget estimate for Medicaid spending would be off.

Expect more talk as election nears

In the meantime, Medicaid seems certain to remain a hot-button issue in Jefferson City.

Indeed, State Auditor Nicole Galloway, a Democrat running for governor in 2020, hit Parson, her likely opponent, over the issue at the State Fair last week in a question-and-answer with reporters.

“He cannot defend why 95,000 kids have been kicked off of health care,” she said, according to the St. Louis Post-Dispatch.

Quade piled on this week after Parson called a special session next month to deal with a court decision barring car buyers from using more than one trade-in to reduce their sales tax bill.

“Roughly 100,000 Missouri children have lost their state health care coverage, but the Parson administration says there’s no problem," she wrote in a news release. "There are several issues that demand immediate legislative attention ... Creating another unnecessary tax break for a handful of people isn’t one of them.”

Daniel Ponder, a political science professor at Drury University, wasn’t surprised, saying both parties had arguments to make.

Republicans, he said, could cast themselves to 2020 voters as “good stewards of taxpayer dollars” making sure everyone getting taxpayer-funded benefits is following the rules.

Democrats, on the other hand, could talk about the impact of the changes on children and emphasize how Republicans have refused to open hearings despite the issues with the renewal process and the number of children involved.

He also said the decrease would “absolutely” play into a potential push to get Medicaid expansion on the ballot next year.