Since April 1st, approximately 1.5 million people have been dropped from Medicaid coverage as states unwind enrollment of beneficiaries in the wake of the ending of the Covid-19 public health emergency. Between eight and 24 million Americans could eventually lose their Medicaid coverage this year, according to the Kaiser Family Foundation (KFF), a nonpartisan health policy organization.
Leading the pack of states with the highest disenrollment rate is Florida, which has already removed several hundred thousand people from the Medicaid rolls. For those whose cases were decided in May, over 50% were disenrolled in Arkansas, Idaho, Kansas, Nevada, New Hampshire, Oklahoma, South Dakota, Utah and West Virginia.
There’s a back story to this considerable disruption in Medicaid, and it has to do with something that occurred six months ago in Congress. Last December, Congressional leaders reached a sweeping health policy deal. The omnibus bill contained a number of healthcare stipulations, including an easing of Medicare pay cuts to physicians, modest investments in future pandemic preparedness and major changes to Medicaid enrollment policy.
The legislation paved the way for state Medicaid agencies to restart “eligibility redetermination” after a three year hiatus caused by the Covid-19 pandemic. At the outset of the Covid-19 pandemic in 2020, the legislative and executive branches of government recognized that a health crisis of this magnitude would be a particularly bad time for people to be without access to healthcare coverage. Therefore, they required that states keep people on Medicaid as long as the nation was officially in a public health emergency. Formally, the policy was known as “continuous enrollment,” and it included appropriation of federal funds to states to expand Medicaid enrollment.
As of the most recent available data released in February of this year, more than 93 million people nationwide were enrolled in Medicaid. Between March 2020 and April 2023 there was an increase of more than 23 million Medicaid beneficiaries. The numbers swelled because federal law prohibited states from disenrolling people from Medicaid while the Covid-19 public health emergency was in place.
But the omnibus bill enacted last December stipulated that states could begin kicking beneficiaries off of the Medicaid rolls as soon as April 1st, and subsequently run checks on Medicaid enrollees to ensure they’re eligible for the program. Now that redeterminations have resumed, states are reviewing the backlog of cases extending back to 2020 to determine whether people are still eligible for Medicaid. States have a year to complete the process.
The people most impacted by this process of eligibility redetermination are those who signed up for Medicaid coverage during the Covid-19 pandemic. Many enrollees may now have incomes too high to qualify for Medicaid and yet they can’t transition expeditiously (or at all) to alternative coverage offered by the Affordable Care Act’s insurance exchanges or employers. Many others may continue to meet Medicaid eligibility criteria but lose coverage for failure to comply with the burdensome administrative hurdles. The eligibility redeterminations are cumbersome to navigate for enrollees who get dropped but would then like to reenroll. Compounding the problem is the fact that some states appear to make signing up for and reenrolling in Medicaid quite difficult.
Vulnerable people, such as children, are especially prone to falling through the cracks. To illustrate, under provisions included in the omnibus bill adopted in December of last year, states must adopt “continuous eligibility” for children in both Medicaid and the Children’s Health Insurance Program. Nonetheless, while these stopgaps exist in theory for children, advocates fear that in practice many households losing coverage include children who are actually still eligible. Indeed, a report issued last year by the U.S. Department of Health and Human Services forecast that more than 50% of children who states would disenroll are in fact Medicaid-eligible.
Granted, it’s not an easy task for states to track down enrollees and guide them on their potential path back to being reinstated as Medicaid beneficiaries. Efforts by state Medicaid agencies to conduct outreach, education and provide enrollment assistance can help ensure that those who remain eligible for Medicaid are able to retain coverage while those who are no longer eligible can transition to other sources of coverage.
Some beneficiaries who become disenrolled can get coverage through their employers. Nevertheless, many employers don’t offer healthcare benefits, particularly in the food, hospitality and unskilled service sector. Others will try and obtain affordable coverage on the individual market through exchanges set up by the state. But for many people this can be a bureaucratic challenge, too.
The Centers for Medicare and Medicaid Services (CMS) have offered guidance to states and have even imposed certain requirements. For example, CMS requires states to submit “renewal redistribution plans” that describe how the state will prioritize reenrollments, how long the state plans to take to complete the renewals as well as the processes and strategies the state is considering or has adopted to reduce “inappropriate coverage loss” during the unwinding period. States were told to submit their plan to CMS by February 15, 2023. Yet, as of mid-May, 20 states had not posted their renewal redistribution plan.
Moving forward, how states deal with the unwinding process will have important implications for the ability of eligible individuals to retain or renew coverage. Here, states have been given perhaps too much leeway. Evidence from the first few months of redeterminations indicates that approaches to unwinding enrollees vary enormously from state to state.
And if the recent past is any indication, the unwinding of Medicaid coverage will have negative repercussions with respect to people’s health insurance status. In a study carried out by KFF that includes the 2016-2019 period, researchers found that during the year following disenrollment from Medicaid, two-thirds of people experienced uninsurance at some point.
Medicaid expansion during the Covid-19 pandemic helped stabilize the situation for these folks and many others. In fact, the share of people who lack health insurance coverage dropped to 8.6% in 2021, an historic low.
However, as states now pursue Medicaid disenrollment, the coverage gains will likely be reversed. The Congressional Budget Office projects that 6.2 million people who are disenrolled from Medicaid over the next 18 months will become uninsured. This is obviously not a desirable policy outcome.
So while extension of continuous enrollment in Medicaid would cost states money, the alternative, a larger un- and uninsured population, is also costly to healthcare systems, patients and society as a whole. Many people will find it very difficult to obtain coverage through their employer or by alternate means. Without coverage, many may postpone necessary care, and some who get sick may wind up putting additional pressure on already stretched emergency care services.
As in any policy calculation, it’s advisable to consider the opportunity cost, that is, assess what’s given up in terms of costs and benefits when a consequential decision is made. Otherwise, a penny wise, pound foolish policy may ensue: Save money in the short term, but exacerbate the already tenuous situation many Americans find themselves in with regard to healthcare coverage, which in turn leads to greater costs for the healthcare system.
Rarely are debates in Washington D.C. or state capitals conducted using the opportunity cost principle. But whenever a policy as far-reaching as eliminating continuous enrollment in Medicaid is considered it would seem prudent to weigh the costs of foregone alternatives.
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