Up to 30 million of the poorest Americans could be purged from the Medicaid program, many the result of error-ridden state reviews that poverty experts say the Biden administration is not doing enough to stop.

The projections from the health consulting firm Avalere come as states undertake a sweeping reevaluation of the 94 million people enrolled in Medicaid, government’s health insurance for the neediest Americans. A host of problems have surfaced across the country, including hourslong phone wait times in Florida, confusing government forms in Arkansas, and children wrongly dropped from coverage in Texas.

“Those people were destined to fail,” said Trevor Hawkins, an attorney for Legal Aid of Arkansas.

Hawkins helped hundreds of people navigate their Medicaid eligibility in Arkansas, as state officials worked to “swiftly disenroll” about 420,000 people in six months’ time. He raised problems with Arkansas' process — like forms that wrongly told people they needed to reapply for Medicaid, instead of simply renew it — with the Centers for Medicare and Medicaid Services.

Nothing changed, he said.

“They ask questions but they don’t tell us what is going on,” Hawkins said of CMS. “Those should be major red flags. If there was a situation where CMS was to step in, it would have been Arkansas.”

Nearly a dozen advocates around the country detailed widespread problems they’ve encountered while helping some of the estimated 10 million people who've already been dropped from Medicaid. Some fear systemic problems are being ignored.

In a statement Tuesday, the Health and Human Services Department said it is monitoring states like Texas, Florida and Arkansas, which account for a quarter of the country's Medicaid disenrollments.

“These and other states need to do more to protect coverage,” HHS said in an email. “We have put all states on notice and will not be afraid to take enforcement action.”

Congress ended a COVID-19 policy last year that barred states from kicking anyone off Medicaid during the pandemic, requiring them to undertake a review of every enrollee's eligibility over the next year. But the Democratic-led Congress also gave HHS Xavier Becerra the power to fine states or halt disenrollments if people were improperly being removed.

HHS has shared little about problems it has uncovered.

Earlier this year, the agency briefly paused disenrollments in 14 states, but it did not disclose which states were paused or for what reasons.

In August, HHS announced thousands of children had been wrongly removed in 29 states that were automatically removing entire households, instead of individuals, from coverage. CMS required the states to reinstate coverage for those who had been terminated under that process, said Daniel Tsai, the director of the CMS Center for Medicaid and Children’s Health Insurance Program Services.

“We are using every lever that we have to hold states accountable," Tsai said.

Florida tried twice to remove Lily Mezquita, a 31-year-old working mom in Miami, from Medicaid during her pregnancy this year. She pleaded her case in 17 phone calls — some with wait times stretching as long as two hours — before she was finally reinstated in August from her hospital bed while in preterm labor. Mezquita would explain the state's law, which says she's guaranteed coverage through her pregnancy and 12 months after giving birth.

“No matter how much I tried to explain, no one was willing to listen,” she said. “They’re making errors, and they’re very confident in their errors.”

Because her coverage didn’t immediately register in the state’s system, Mezquita paid out-of-pocket for pills doctors prescribed to prevent pre-term labor from arising again, and she missed follow-up appointments to check on her baby girl.

If trends continue, as many as 30 million people could end up being dropped from Medicaid at some point once states finish reviewing their Medicaid rolls, according to Avalere's projections. The numbers dwarf the Biden administration’s initial projections that only 15 million people would lose coverage throughout the process.

“We have to say it’s going poorly,” Massey Whorley, a principal at Avalere, said of the Medicaid redeterminations. “This has been characterized by much higher-than-expected disenrollment.”

Most have been removed for procedural reasons, like failing to send back their renewal form or mail in proper paperwork. That points to bigger problems with how the states are determining Medicaid eligibility: Their notices aren't reaching people, don't make sense or they're requiring unnecessary paperwork. Many of the people removed for those reasons may still qualify for Medicaid and might eventually be re-enrolled.

In Arkansas, which has finished its Medicaid redeterminations, public records shared with the AP show more than 70% of people were kicked off Medicaid because the state couldn’t reach them or they didn’t return their renewal form or provide requested paperwork.

“I can’t say how many calls I’ve gotten from people who just got out of the emergency room and found out they don’t have coverage,” Hawkins said.

The state's Department of Human Services says it tried to reach people with additional calls, emails and texts. It believes the high number of procedural disenrollments were the result of people who no longer qualified for Medicaid not mailing back their renewal forms, spokesman Gavin Lesnick told AP in an email. Lesnick said CMS has never asked Arkansas to pause disenrollments.

Long phone wait times and notices that don't include reasons why people are being kicked off Medicaid have plagued the process in Florida, said Lynn Hearn, an attorney at the Florida Health Justice Project. Hearn helped Mezquita appeal her case to the state. Earlier this year, the nonprofit sued the state over its handling of the process.

“We’ve seen CMS reluctant to step in on the issues that we’ve raised,” Hearn said. “We have seen errors in state processing that indicate more than anomalies — more like systemic issues."

The Florida Department of Children and Families has had an 87% response rate to its renewal forms and call wait times are under five minutes, spokeswoman Mallory McManus said in an email.

Medicaid enrollees in North Carolina, meanwhile, are also having trouble reaching their local office by phone or getting calls returned when they leave a message, said Cassidy Estes-Rogers, the director of family support and healthcare at the Charlotte Center for Legal Advocacy. State officials didn't immediately respond to questions about phone troubles.

Estes-Rogers said she meets regularly with local CMS officials about problems.

“They just don’t come back to us with any information on how that was resolved, and we don’t see any immediate effects from it,” she said.

Similar problems have arisen in Texas, where website and app outages have meant families don't even get the electronic notices stating their Medicaid coverage was up for renewal, said Graciela Camarena, the child health outreach program director for the Children's Defense Fund in Texas.

"They were visiting the doctor's office or the pediatricians' office — that's where they found out they were denied," Camarena said.

Camarena said CMS has met with her organization to go over some of the issues and has been pleased with its help. Some Texas lawmakers have asked CMS to investigate issues in the state, where nearly 1 million have lost Medicaid.

CMS has not asked the state to stop the process, Texas Health and Human Services spokeswoman Jennifer Ruffcorn said in an email. The agency “is continuously working to improve” its app and website, she added.

Local groups have also been funneling up problems to national groups that CMS meets with weekly, Tsai said. In some cases, issues raised to the agency don't violate federal regulations.

“However," Tsai said, “You look at what's happening and you say, ‘how is this a good, consumer friendly-process?’”

CMS has tried to play nice with states on Medicaid, hoping they can help improve the enrollment process for many years to come said Jennifer Wagner, the director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities. The organization has been working with local groups to notify CMS of problems.

“There is a question, in some states, if it’s time to shift toward enforcement," she said.