Millions of the most vulnerable Americans could lose their Medicaid insurance when the pandemic ends, and some state officials are worried they might not have enough time or resources to help people find new coverage.
States expect the current federal public health emergency to expire this year, triggering a requirement that they must comb through their Medicaid rolls to see who is no longer eligible. Those audits, which have been suspended for the past two years, could lead to as many as 15 million people losing their health insurance, including 6 million children, according to an analysis from the Urban Institute.
While the Biden administration plans to allow states up to a year to complete their work, a half-dozen state Medicaid, welfare and health insurance exchange agency heads told POLITICO that not having a firm date for when their work is supposed to start is complicating efforts to prepare for what is likely the biggest shift in the health insurance landscape since the Affordable Care Act passed more than a decade ago.
“There’s not a lot of runway here,” Jeff Nelson, director of Utah’s Bureau of Eligibility Policy, told POLITICO. “It’s hard for us to not know what’s going to happen.”
The Biden administration recently extended the public health emergency another three months, through April 15, but the White House is likely to allow it to expire once Covid-19 cases wane and vaccinations increase.
Congress could help, they say, if it decouples the requirement to keep people on state Medicaid rolls from the public health emergency and sets a date for when the pandemic-era policy will end. State officials are also asking federal lawmakers for more money and eyeing additional requirements for the unwinding effort, which some say could safeguard against pressures from state lawmakers to expedite the process in order to save money and remove people from welfare rolls as soon as possible.
People typically lose Medicaid coverage because their income increases above the eligibility threshold, or they fail to submit the proper paperwork to prove they qualify. But when the pandemic began, Congress, in exchange for additional federal funding, barred states from kicking people off Medicaid. Enrollment surged nearly 20 percent over the next 16 months to 76.7 million, according to the Centers for Medicare and Medicaid Services, an all-time high.
Now, states fear that unwinding the expanded social safety net could prove messy — as many of the millions removed from the rolls may not know they’ve lost their health insurance or which options are available for new coverage. It’s a problem not just for states but for the Biden administration, which might be forced to grapple with rising uninsured rates in an election year.
“Most of us go to sleep at night thinking about this and what we can do the next day around this,” said Daniel Tsai, director of the Center for Medicaid and CHIP Services, describing the level of engagement across HHS and CMS on this issue as “unprecedented.”
“We are pulling out all the stops,” Tsai said.
Utah, which undertook a similar effort last year for its Children’s Health Insurance Program, offers a preview of what the rest of the country could experience. More than 41 percent of the 15,000 kids enrolled in Utah’s program lost their health insurance during the redetermination process — despite the state’s efforts to reach out to people, update addresses and send out notifications in advance.
“So maybe, just maybe, we are a canary in the coal mine, or maybe, just maybe, we are a cautionary tale for some other states on what needs to happen,” Nelson told the Medicaid and CHIP Payment and Access Commission last week.
State health officials say a firm date would allow them to hire and train additional staff amid an ongoing workforce shortage, build out call center capacity to limit wait times and conduct outreach campaigns with local community organizations to ensure enrollees know they need to provide certain information to the state to keep their coverage.
“That’s really one of the big risks, that people will be eligible but become unenrolled just because they don’t get the message and don’t know how to continue their coverage and are just out of the habit, quite honestly, of doing renewals and redeterminations after almost two years,” said Suzanne Bierman, administrator of Nevada’s Medicaid program.
Start the process too early, and states worry they’ll be paying for resources they don’t yet need and wasting what might be the one shot they have to communicate with a vulnerable population. Start too late, and states might not have the infrastructure in place to help hundreds of thousands of residents re-enroll in Medicaid or transition to coverage on state health insurance exchanges.
While states are accustomed to some level of uncertainty from the federal government, Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, said this is a unique situation.
“Just not knowing how much longer this will be in place is creating significant challenges,” Tolbert said. “The pressures are heightened and the uncertainty is even greater.”
Without a firm date, state health officials say they are doing what they can, including asking enrollees to update their contact information — like addresses, phone numbers and emails — so the state will be able to find them once the actual redetermination process starts.
In Pennsylvania, state Medicaid and exchange officials are shoring up the data transfer process to make it easier for people to sign up for an Obamacare plan if they lose their Medicaid coverage.
In Massachusetts, the state invested $5 million in a community-based Medicaid redetermination and vaccination outreach campaign to communities hit hardest by the pandemic.
And in New York, Gov. Kathy Hochul’s budget included an additional $69 million to the state health department’s budget, some of which the agency says will be used to facilitate the unwinding of the public health emergency.
“We have a big job ahead of us. We know that already,” New York Health Commissioner Mary Bassett told reporters last week. “Our goal is to make it orderly and keep people insured.”
State health officials credited the Biden administration with offering some help, pointing to assurances early last year that the public health emergency would run at least through the end of 2021, and that states would have 60 days’ notice before it ended. CMS also released guidance last summer that answered some of states’ most pressing questions and a best practices list in November as states prepare for the end of the continuous enrollment requirement. There are also calls at least twice a month between state and federal officials.
“We are highly cognizant that states kind of need to know an end date to get things moving,” Tsai said. “Our message has been, ‘We should just plan for that coming as soon as possible.’ Not to say it will be … but the answer is, ‘Do not sit and wait.’”
Jennifer Wagner, director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities, a left-leaning think tank, worries that some states may welcome the chance to purge their welfare rolls and do little to help people prove their eligibility or find new coverage.
“What we have seen historically is that so many eligible people get caught up in the chaos of this, of states not doing good ex parte [renewals], of not updating addresses, not leveraging SNAP information for addresses or income or other things, relying on paper-based mail instead of any effort to phone calls or text messages or other things,” she said.
Medicaid experts point to Ohio — where the state has contracted with an outside vendor that will automate eligibility redeterminations in exchange for a cut of state Medicaid savings and plans to process redeterminations in 90 days — as a particularly concerning case. The Ohio Department of Medicaid declined to comment.
Medicaid advocates are also concerned that states may have a financial incentive to clear their rolls as quickly as possible. The additional federal matching funds that Congress provided to help pay for the swelling Medicaid rolls will be cut at the end of the quarter in which the public health emergency ends, giving states a reason to rush through the process instead of taking the full 12 months the Biden administration has said it will allow.
Democrats proposed extending those additional federal payments as part of their social spending package, but the effort is stalled in Congress.
Medicaid advocates caution that the faster states rush through the process, the greater the chance eligible individuals could lose coverage for not filling out the right paperwork. Kicking people off state Medicaid rolls who are eligible stands to not only disrupt patient care — meaning less management of underlying conditions at doctor’s offices and more utilization of higher-cost care in hospitals — but also could cost states down the road in staff time to reprocess those individuals if and when they reapply for Medicaid.
It’s also likely to have a disproportionate impact on low-income communities of color, given that more than half of Medicaid recipients identify as Black, Hispanic, Asian American, or another non-white race or ethnicity, according to MACPAC.
Tricia Brooks, a research professor at the Georgetown University McCourt School of Public Policy, warned that states trying to complete redeterminations over a short time period could see call centers quickly overwhelmed — reminiscent of the strain state unemployment systems came under at the beginning of the pandemic.
“When you have an hour wait time at a call center, you can’t expect the consumers are getting the information that they need and you need to be able to hit the pause button,” Brooks said. “I worry that we’re not going to be able to hit the pause button before too much damage is done.”