Researchers Express Concern Over the Unwinding of Medicaid Enrollment

Feb. 27, 2023
A team of healthcare policy researchers has expressed deep concern over the unwinding of continuous Medicaid enrollment after the Public Health Emergency ends on May 11

In a “Perspective” op-ed column in The New England Journal of Medicine online, a team of healthcare policy researchers has expressed deep concern over what will happen as the Public Health Emergency (PHE) ends on May 11. The article, “Unwinding Continuous Medicaid Enrollment,” was written by Sara Rosenbaum, M.D., Sara R. Collins, Ph.D., MaryBeth Musumeci, J.D., and Alex Somodevilla, J.D., and published online on Feb. 22.

The authors begin by stating that “The U.S. Families First Coronavirus Response Act (FFCRA) was enacted in March 2020, as the Covid-19 pandemic arrived in the United States and the federal government issued the first federal public health emergency declaration. The FFCRA provided, among other reforms, that unless Medicaid beneficiaries voluntarily disenrolled or left their current state of residence, they would remain continuously enrolled without a break in coverage until the emergency period ended. The continuous-enrollment guarantee addressed a basic weakness of Medicaid known as “churn”: frequent coverage breaks resulting from small changes in life circumstances or program operational intricacies that can cause disenrollment among people still eligible for assistance. Of course, breaks in coverage are possible with almost any form of insurance,” they acknowledge, “but churn is especially notable in Medicaid because of its sensitive eligibility rules and the complexity of program administration.1 Although the Affordable Care Act simplified Medicaid enrollment and renewal procedures, eligibility reviews continue to pose a major challenge for beneficiaries and agency staff alike. The effects of coverage interruption or loss are acute, for both patients and providers in heavily underserved communities.”

They also note that “[I]n December 2022, as part of the Consolidated Appropriations Act (CAA), lawmakers separated Medicaid from this public health emergency framework, instead establishing a fixed end date that would enable states to plan and carry out a more orderly unwinding. The CAA ends continuous enrollment on March 31, 2023; under administration policy, states will have 14 months to complete the process of reviewing eligibility for their entire Medicaid population. Reviews can begin February 1, and eligibility-termination notices can be sent beginning April 1. The Biden administration strongly recommends that states proceed slowly in order to ensure careful reviews and minimize eligibility redetermination errors, but they can choose to move faster.”

And evidently, they note, “Unwinding Medicaid enrollment is a daunting task. The pandemic witnessed a 20% surge in enrollment, with some states seeing their Medicaid rolls grow by as much as 75 percent. By October 2022, Medicaid enrollment (including both Medicaid and its smaller companion, the Children’s Health Insurance Program [CHIP]) surpassed 90 million people.” Importantly, they underscore, “Medicaid’s pandemic performance underscores its outsize role as a critical tool for promoting greater health care equity during public health emergencies. But despite evidence showing that Covid risks remain elevated in the highest-need communities,4 continuous-enrollment protections were destined to end. Now everyone — from states to beneficiaries to the health care system itself — must prepare for what comes next.”

The concern, the researchers note, is this: “[S]ome states, especially those that do not cover all low-income adults, may choose to move especially quickly on the assumption (which could be incorrect) that no other basis for current enrollees’ eligibility exists. Although the Biden administration strongly recommends proceeding slowly, the CAA effectively encourages speed by rapidly sunsetting enhanced federal Medicaid funding. Enhanced funding begins decreasing on April 1, 2023, and entirely disappears at the end of December 2023, only 9 months after the wind-down process begins and well before the 14-month recommended unwinding period ends. The rapid termination of supplemental funding may act as an incentive for expediting the process.” Texas officials, for example, have stated that they expect to disenroll 2.7 million Medicaid beneficiaries out of nearly 5.8 million as of November 2022. The individuals expected to feel the heaviest impact will be low-income women whose coverage was tied to pregnancy but are now beyond their postpartum period, as well as poor young adults who have turned 18. And Texas is one of 11 states that have chosen not to expand Medicaid. What’s more, they note, in some non-expansion states, non-disabled, poor adults without minor children cannot qualify for Medicaid at any income level. The researchers are concerned that moving too quickly could “overwhelm community organizations trying to help find other coverage or to appeal incorrect terminations.”

The scope of this problem is very large, since the federal government is estimating that unwinding the pandemic’s coverage will drop 15 million people from Medicaid coverage. What’s more, there will able delays in processing new enrollments. What’s more, they point, there are no federal safeguards to protect individuals with very serious levels of chronic illness.

In the end, the article’s authors state, “There is no good time to unwind Medicaid enrollment, and it was inevitable that this day would come. Even with aggressive mitigation efforts, unwinding will be painful, and the number of uninsured Americans will most likely grow nationwide. Medicaid unwinding and its likely aftermath are a reminder of the price Americans pay for a health system that fails to guarantee universal, stable, uninterrupted coverage.”

Sarah Rosenbaum and MaryBeth Musumeci are affiliated with the Milken Institute of Public Health at George Washington University (Washington, D.C.), while Alex Somodevilla is an associate in the Washington, D.C. office of the Boston-based Foley Hoag law firm. Sara R. Collins is affiliated with the Commonwealth Fund, New York City.

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