Federal officials are pressuring states to reduce the sizable backlog of Medicaid applications. (Photo by Andrew Harrer/Bloomberg)

Welcome to Health Reform Watch, Jason Millman's regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Jason with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, or sign up here to receive it straight from your inbox. Read previous columns here.

If you're a fan of Obamacare's coverage expansion, the quick and significant boost in Medicaid enrollment the past few months has been one of the law's biggest successes so far. But the rapid jump in Medicaid enrollment has also provided one of the biggest logistical headaches so far, with hundreds of thousand of people, and possibly millions, still waiting for their applications to get processed and their coverage confirmed.

Nearly 7 million people have been added to the rolls for Medicaid and a children's insurance program since Obamacare enrollment opened last fall, but the number of people still caught in an application backlog is hard to pin down. Kaiser Health News last month found 1.7 million people in 15 states were still waiting on their applications, and there's now increasing pressure to get the problem under control.

The backlogs have been known about for some time, but federal health officials at the Centers for Medicare and Medicaid Services have given six states (Alaska, California, Kansas, Michigan, Missouri and Tennessee) until today to provide plans on just how they're going to resolve the huge stacks of pending applications. But some of the states say they're being unfairly targeted by CMS.

The Affordable Care Act is supposed to offer a "no-wrong door" enrollment approach, in which an applicant could show up at a state or federal exchange Web site and sign up for Medicaid coverage if eligible. However, because of early problems with HealthCare.gov, federal officials had trouble sending Medicaid applications back to the states to review applicants' eligibility — and when they did, they sometimes provided wrong or missing data that the states then had to correct. The feds can't take all of the blame, though. Some of the states were slow to update Medicaid eligibility rules, and they've had their own problems replacing outdated enrollment systems.

"It's not surprising that things weren't up and running and ready to go on Oct. 1," said Matt Salo, executive director of the National Association of Medicaid Directors.

Salo offers a couple of reasons to think why the backlogs, though still of major concern, may not be as problematic as feared. The alarming numbers in some states might count people who tried going through HealthCare.gov but later enrolled in Medicaid directly with the state, though we don't know how many might have done this. Medicaid also allows retroactive eligibility, which pays for applicants' health-care services in the months before their enrollment is confirmed. Again, though, it's hard to know how commonly this happens.

Without confirmed enrollment, people may have trouble receiving care or could just give up on obtaining coverage. So, patient advocates in some states are getting increasingly anxious about people caught in the backlogs.

In Tennessee's case, the conversation between the feds and the state hasn't been so friendly. In its letter to Tennessee, posted by Modern Healthcare, CMS says the state has fallen short in six of seven enrollment criteria and that it's been warned several times of federal concerns with the state's enrollment process. But Tennessee denies that it even has a Medicaid backlog, and its Medicaid director suggested the federal government is trying to deflect attention away from HealthCare.gov problems.

"We don’t understand why the federal government no longer wants Tennessee to stay the course with a plan that is largely working — and certainly working better than the alternatives that have created significant backlogs of Medicaid applications across the country," Tennessee Medicaid Director Darin Gordon wrote in an op-ed this weekend. (Update: Tennessee offered a formal response Monday night).

Federal Medicaid officials could continue to put public pressure on the states, but it's not clear what else they would do if the problem persists. CMS could withhold some funding to states, but Salo said that would only take resources away from reducing the backlogs.

The size of the backlogs appears to be getting at least somewhat smaller — California has reduced its sizable wait list from 900,000 to 600,000 in the past couple of months. And though Medicaid enrollment is year-round, Salo said states are especially focused on getting the issue cleared up by the next ACA open enrollment period starting in mid-November.

"We want to make sure we have as much of a clean slate ready for that and not have to be carrying forward the challenges from the previous year," he said.

Top health policy reads from around the Web:

Medicare data reveal more questionable billing practices. "Among the highest billers for group psychotherapy in Illinois were three ob/gyns and a thoracic surgeon. The four combined for 37,864 sessions that year, more than the total for all providers in the state of California. They were reimbursed more than $730,000 by Medicare in 2012 just for psychotherapy sessions, according to an analysis of a separate Medicare data set released in April." Charles Ornstein for ProPublica.

Some doctors are refusing Obamacare coverage. "Nearly one million Floridians enrolled in a private health plan through the ACA exchange but some ... are finding that some physicians refuse to honor their coverage — even when the doctors are included in the plan’s provider network. Some physicians say they’re concerned they won’t be paid for their services by either the insurer or the patient, and that insurers are not adequately informing doctors of their inclusion in exchange plan networks. ... For some patients, though, the elation they felt about being insured has been tempered with rejection at doctors’ offices." Daniel Chang in the Miami Herald.

How much would you pay to see the doctor right away? "Let's say you and I are both trying to see the same top-rated surgeon, and because I'm willing to pay extra, it takes me 24 hours to get an appointment that you need to wait six months for. Would that be upsetting? ... How is growing income inequality affecting the delivery of health care? And is that change for the better?" Christopher Flavelle for Bloomberg View.