The Growing Strain on Medicaid Agencies: Understaffing and New Demands Threaten Access to Healthcare

Katie Crouch’s experience trying to contact her state’s Medicaid agency for information about her benefits felt like navigating a labyrinth. "The first time, the phone rings endlessly. The next, it sends you to voicemail and the call disconnects," said the 48-year-old Delaware resident. "Sometimes someone answers who says they’re not the right person. They transfer you and it disconnects. Sometimes they answer and there’s no one on the line."

Crouch spent months trying to determine if her Medicaid coverage had been renewed. As of late March, she had not yet received her annual renewal for the state and federal program that provides health insurance to low-income individuals and those with disabilities. Crouch, who suffered a debilitating brain aneurysm a decade ago, also has Medicare, which covers individuals 65 and older, or those with disabilities. Medicaid had been covering her $200 monthly Medicare deductibles, but for the past three months, she has had to cover them herself, impacting her family’s fixed income.

Crouch’s struggles with Delaware’s Medicaid call center are not an isolated incident. State Medicaid agencies are facing significant challenges in maintaining adequate staffing levels to assist individuals with enrollment and to address inquiries from beneficiaries. This shortage of essential workers can prevent people from fully utilizing their benefits, according to health policy researchers.

Adding to these existing pressures, the "One Big Beautiful Bill Act," passed by Republicans and signed into law by President Trump last summer, will soon impose even greater demands on state agency personnel. This is particularly true in states that have expanded Medicaid to cover more low-income adults, a move adopted by nearly all states and the District of Columbia. The law, projected to reduce Medicaid spending by nearly $1 billion over the next eight years, requires these workers not only to determine if millions of beneficiaries meet new work requirements for the program but also to verify their eligibility more frequently – every six months instead of annually.

KFF Health News contacted agencies that will be implementing these work rules, and many indicated a need for additional staff. These heightened requirements will place further strain on an already overburdened workforce, potentially making it harder for beneficiaries like Crouch to receive basic customer service. Many could lose access to benefits they are legally entitled to, according to consumer advocates and health policy researchers, some with direct experience working within state agencies.

"States are already ‘struggling mightily’," said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities and former deputy director of the Illinois Department of Human Services. "There will be significant additional challenges because of these changes."

Lengthy Wait Times for Assistance

Republicans contend that the changes to Medicaid, set to take effect on January 1, 2027, in most states, will incentivize beneficiaries to find employment. However, research on other Medicaid work requirement programs has found little evidence that they increase employment. The Congressional Budget Office (CBO) estimated that these rules would lead to more people losing health coverage by 2034, with projections indicating that over 5 million individuals could be affected.

Many states are already struggling with insufficient staff to process Medicaid applications or renewals in a timely manner, advocates say. The Centers for Medicare & Medicaid Services (CMS) monitors whether states can process the most common type of benefit application within a 45-day timeframe. In December, approximately 30% of all Medicaid and Children’s Health Insurance Program (CHIP) applications in Washington, D.C., and Georgia took longer than 45 days to process. More than a quarter took that long in Wyoming. In Maine, one in five applications missed this deadline.

CMS began publicly sharing data from Medicaid call centers in 2023, revealing a system under considerable pressure, according to researchers and advocates. In Hawaii, individuals faced wait times exceeding three hours on the phone in December. In Oklahoma, the wait was nearly an hour, and in Nevada, over an hour.

In 2023, state Medicaid agencies began re-verifying the eligibility of beneficiaries who had been shielded from losing coverage during the COVID-19 pandemic. This process, known as "Medicaid unwinding," did not go smoothly in many states, resulting in more than 25 million people losing their benefits. Researchers and advocates anticipate that implementing the new work rules will present an even greater challenge. The work requirements will necessitate extensive changes to IT systems and training for eligibility workers operating under tight deadlines.

"It’s a much higher level of administrative complexity," noted Sophia Tripoli, policy director at Families USA, a consumer health advocacy organization.

After months of attempting to reach someone, Crouch eventually received answers about her Medicaid benefits after writing to the office of U.S. Representative Sarah McBride (D-Delaware). Her office contacted the state Medicaid agency, which finally called her with an update. Crouch, it turned out, did not actually qualify for Medicaid. She stated this had never come up in two years of interactions with the state. "It makes no sense that the state didn’t realize this sooner," she said. The Delaware Medicaid agency did not respond to requests for comment on her case.

States Grapple with Understaffing for Medicaid Operations

As of late March, several states informed KFF Health News that they would require additional staff to effectively implement the work rules. Idaho reported 40 vacancies for eligibility workers. New York estimated needing 80 new employees to manage the additional administrative workload, at a cost of $6.2 million. Pennsylvania has nearly 400 open positions in county human services offices. Indiana’s Medicaid agency has 94 vacancies. Maine aims to hire 90 additional workers, and Massachusetts seeks to add 70 more. Montana has filled 39 of the 59 positions it deems necessary.

Missouri’s social services agency has seen staff reductions, with 1,000 fewer frontline workers than approximately a decade ago, despite more than double the number of beneficiaries in Medicaid and the Supplemental Nutrition Assistance Program (SNAP). According to comments from its director, Jessica Bax, in a November public meeting, "The department thought there would be an improvement in efficiency through eligibility system upgrades. Many of those improvements did not materialize."

States may face difficulties in finding individuals interested in these roles, which require months of training, can be emotionally taxing, and generally offer low wages, stated Tricia Brooks, a researcher at the Georgetown University Center for Children and Families. "They receive a lot of complaints and yelling," said Brooks, who previously led Medicaid and CHIP customer service programs in New Hampshire. "People are frustrated. They cry. They are worried. They are losing access to medical care, and it’s not an easy job when it’s difficult to help."

States are spending millions of dollars on government contractors to assist with compliance for the new federal law. Maximus, a government services contractor, provides eligibility support, including call center management, in 17 states that expanded Medicaid and serves nearly 3 in 5 individuals enrolled in the program nationally, according to the company. During an earnings call in February, the company indicated it can charge based on the number of transactions it handles for beneficiaries, regardless of how many people are enrolled in the program in a given state.

Maximus does not have a "one-size-fits-all approach" to the services it offers or how it bills for them, its spokesperson Marci Goldstein told KFF Health News. The company, which reported $1.76 billion in revenue in 2025 in the segment including Medicaid-related work, expects this revenue to continue growing, even if fewer people remain in the program, "due to the increased transactions that will be necessary," noted David Mutryn, Maximus’s chief financial officer and treasurer.

Losing Medicaid coverage is more than just an inconvenience, as many enrolled individuals likely do not earn enough to afford medical care on their own and may not qualify for financial assistance under the Affordable Care Act (ACA). This could lead to an inability to afford medications or receive essential care, with potentially "devastating" impacts on health, said Elizabeth Edwards, an attorney with the National Health Law Program. "What’s at stake are people’s lives," she concluded.

KFF Health News correspondents Katheryn Houghton and Samantha Liss contributed to this article.