Millions Face Coverage Cliff as Public Health Emergency Unwinds
At the start of the COVID-19 pandemic, Congress established protections for Medicaid enrollees to stay on their health coverage during the Public Health Emergency (PHE) known as continuous eligibility. However, in December of 2022, Congress de-linked the Medicaid and Children’s Health Insurance Program (CHIP) continuous eligibility requirements from the declaration of the PHE, setting a start date of April 1, 2023 for when states can begin disenrolling people from Medicaid and CHIP coverage.
Who will be impacted?
Estimates predict that between 5 million to 18 million people will lose coverage or be forced to transition to other forms of coverage because of changes in income or life circumstances. The Centers for Medicare & Medicaid Services (CMS) has announced a Special Enrollment Period (SEP) to mitigate some of these coverage losses. However, an estimated 7 million people who are still eligible for Medicaid or CHIP could lose coverage simply because of procedural issues like incorrect contact information. Luckily, Congress put into place some safeguards and requirements for states, along with financial incentives and penalties to encourage a careful redetermination process. As states prepare for this shift, they must ensure they have robust plans, as required of them and adequate staffing in place.
The Medicaid unwinding will impact different communities in different ways. During the public health emergency, children, people of color and adults who got coverage under Medicaid expansion saw the largest gains in coverage and thus stand to lose coverage at higher rates. Upward of 250,000 American Indian/Alaska Native people may lose coverage. People with limited English proficiency, who are deaf, hard of hearing, blind or visually impaired may face challenges to find resources and support in their primary language, American sign language or braille. Immigrants will need reassuring messages that reapplying for health care coverage will not impact their or a loved one’s immigration status. Navigating coverage for gender affirming health care may also be particularly challenging for transgender and nonbinary people seeking services especially when transitioning from Medicaid to other health insurance plans that may not be explicit in what they cover.
Additionally, people with complex health needs, especially those who are eligible for both Medicare and Medicaid, people with disabilities, and people with substance use disorders will experience unique challenges with navigating the Medicaid redetermination process. Suddenly losing health insurance means people could be cut off from essential medications and services, which could be particularly dangerous, and potentially deadly, for people with substance use disorders, as lapses in treatment can result in dangerous return to drug use, putting the person at risk for fatal overdose. Compared to those only enrolled in Medicare, Medicare-Medicaid enrollees need more supports for daily living, have higher rates of poverty and have communications needs. Without specialized support to navigate the redetermination process, many will lose Medicaid services that enable their independent living and experience dangerous and costly interruptions in care.
Loss of Medicaid will also eliminate the financial supports that make Medicare insurance for dually eligible people affordable, such as lowered premiums and protections from deductibles and co-insurance. The PHE also permitted regulatory flexibilities for disability service providers, like expanded service settings, and the ability to provide temporary direct support wage increases and pay family caregivers which may lead to higher vacancy and turnover rates in the workforce once expired.
As people transition from public coverage programs like Medicaid to other forms of coverage, their benefits and costs may also change. For example, people who rely on Medicaid for oral health coverage who end up uninsured will lack access to dental as well as medical care. Even if someone successfully transitions to private insurance through an employer or the Marketplace, they may lose dental benefits they previously had covered under Medicaid because adult dental is not considered an essential health benefit. This puts people at greater risk of incurring medical debt, of which dental care is a key contributor.
The PHE unwinding also puts low-income adults who are shut out of affordable Marketplace plans and cannot access health coverage because their states have not expanded Medicaid. In the 10 remaining non-expansion states undergoing redeterminations, hundreds of thousands of people, of which people of color make up 60 percent due to longstanding and systemic barriers to care, could lose their Medicaid coverage with no other affordable coverage option available to them. If transitioning to other coverage is not possible, the likelihood of medical debt increases. In a 2016 study, 53 percent of uninsured patients had problems paying medical bills, compared to only 18 percent of those with Medicaid coverage.
Beyond the Medicaid issues, many of the PHE-related policies will begin to phase out once the PHE officially ends on May 11. As such, the Biden administration and states are actively considering strategies to ensure continued access to no-cost COVID-19 vaccines, testing and treatment, especially for the uninsured. Congressional action extended Medicare telehealth flexibilities, but it is up to individual states to implement it for Medicaid and CHIP, and most states have committed to making those flexibilities permanent.
What can state advocates and state Medicaid agencies do?
Local, state and national advocates are working tirelessly to ensure that Medicaid enrollees do not experience lapses in coverage. As such, resources and advocacy opportunities have been developed and identified by partners across the country.
- Utilize Centers for Medicare & Medicaid Services (CMS) Unwinding and Returning to Regular Operations after COVID-19 webpage and this state-by-state tracker which provides an overview of how individual states are preparing for the unwinding.
- Use these outreach and enrollment materials available in up to 20 languages when connecting with trusted community members and partners.
- Push your state Medicaid agencies to publicly publish their unwinding operational plans, plans for communicating with Medicaid and CHIP enrollees, and their corrective action plan if your state anticipates not being able to meet federal requirements for redetermination.
- Assess these plans to ensure the needs of dually eligible people, immigrants, transgender and nonbinary people are taken into account.
- Encourage your state Medicaid agencies to hire more eligibility workers at the 75 percent federal match to increase staff capacity.
- If you work with directly impacted people, provide guidance on how they can prepare, including support with ensuring their Medicaid agency has their correct contact information.
- Effectively communicate how benefits differ between Medicaid/CHIP and Marketplace or employer coverage. As people transition, they’ll need to be aware of what is no longer available or what they may have to pay for out-of-pocket.
- Partner with trusted community partners and providers, including community-based organizations, community members, community health workers, Indian Health Care Providers and Tribal enrollment assisters, and LGBTQ+ competent enrollment assisters to get information to people who may have limited English proficiency, have a disability, where postal mail and/or broadband access are limited and for transgender and nonbinary people.
- If you’re in a non-expansion state, utilize the unwinding to continue to leverage the case for Medicaid expansion.