Nebraska's Medicaid Hold Time Doubled to 26 Minutes. A Cancer Patient Canceled His Scan.

The call came from the hospital, not from Medicaid. Eli McCreary was 64, living in Omaha, and newly diagnosed with cancer in his right kidney. He also has diabetes and COPD. He told KFF Health News the hospital informed him he wasn't insured anymore, and that his appointments would be canceled unless he paid out of pocket.

So he canceled the CT scan. He put off a cancer appointment with a physician who travels in and out of Omaha, and he missed that window for another month.

Then he did what you're supposed to do. He called for help. The number he remembers dialing wasn't even the state's Medicaid line. It was an outsourced call center for food stamp accounts. Someone there told him he hadn't met his work requirement.

"I can't walk. I can hardly breathe. I can't move around," he said. "What job am I going to get?"

Here's the part that makes the story worse. Nebraska's health department says work rules were never the reason. He turned 65 and aged out of Medicaid and into Medicare. The state says he had "no lapses in coverage." He's on Medicare now, Medicaid covers some of his costs, and he rescheduled. He had surgery in early November to remove the kidney.

"The cancer has grown so much," he said.

Nobody in that story botched a surgery or misread a scan. Every bit of the harm happened in the paperwork, somewhere between a hospital's coverage check, a phone tree, and a call center run by a private company, and it landed on a man who could hardly breathe.

Nebraska wanted to go first on the new Medicaid work rules, and it did, launching May 1, 8 months ahead of most states. About 70,000 adult Medicaid recipients there are subject to them. They have to prove 80 hours a month of work or a similar activity, unless they qualify for an exemption. By August, roughly 1,100 Nebraskans had been denied benefits because of the rules. Most of those denials came from requests for information that never got answered.

The phones tell the rest. Average wait time at the state's call center nearly doubled between May and July, from about 13 minutes to 26. In August the state took more than 101,000 calls, a 66% jump from May. State documents outline $8.2 million over 2 years in contractor costs to carry out the changes, with at least 6 contractors costing more than $250,000 each and 1 person whose compensation tops $1.8 million. The state says those funding requests "may not reflect actual expenditures."

The state's own scorecard looks fine. 86% of affected applicants met the requirement or qualified for an exclusion, and 93% of existing enrollees kept their coverage. I believe those numbers. I also believe Kenny McMorris, who runs the Charles Drew Health Center in North Omaha, where roughly half of 13,385 patients are on Medicaid. "If people are working, they just don't have time to be sitting on the phone to go through all of this stuff," he said.

Next year, work requirements reach millions of adult Medicaid enrollees in more than 40 states. The Congressional Budget Office estimates the policy will leave 5.3 million more people uninsured by 2034. People will argue about work requirements as policy for years. What I care about is the machinery that enforces them, because it's the same machinery that wrecks primary care: forms, verification, hold music, and a third party standing between a sick person and a doctor.

I've spent my career trying to get that third party out of the exam room. Every layer you add costs money, and it costs time, and the time comes out of the patient. McCreary's tumor didn't wait for anyone to sort out which program he belonged to.

Direct care can't settle Medicaid eligibility. It can't pay for a kidney surgery. What it can do is keep the front door simple. 1 monthly price. A doctor whose number you actually have. When a test turns up something scary, the next call goes to someone who knows your name, and the first question is about your kidney, not your card.

That's the whole idea. The more paperwork a system needs to decide whether you count, the less doctor you get for your money.

26 minutes on hold is a price. A month of a growing tumor is the bill.

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