A photo of a folder labeled: FFCRA Families First Coronavirus Response Act, laying on an American flag.

Reviews | A self-inflicted wound: the impending loss of coverage

President Biden recently declared the pandemic to be “over”. Regardless of what you think of this statement or its clarification, it is clear that state and federal health policy goes and goes in the direction of acting as if the pandemic is indeed over. And with that, a big shoe yet to fall looms on the horizon – millions of Americans are on the verge of losing their Medicaid coverage, though many will still be eligible. This equates to a self-inflicted wound of loss of coverage and a potential crisis for access to health care, simply because of the paperwork.

An August report from HHS estimated that about 15 million Americans will lose coverage from Medicaid or the Children’s Health Insurance Program (CHIP) once the federal declaration of a public health emergency (PHE) COVID -19 will be allowed to expire. Of those 15 million, 8.2 million are expected to be people who are no longer eligible for Medicaid or CHIP — but almost as many (6.8 million) will become uninsured despite still being eligible.

Why does this happen?

This Medicaid “cliff” will happen because the additional funding states receive under the Families-First Coronavirus Response Act (FFCRA) since March 2020 depended on keeping everyone enrolled by shutting down all bureaucracy that determines whether people are still eligible. Once all eligibility redetermination processes resume, the lack of up-to-date contact information, document requests, and other administrative burdens will leave many falling through the cracks. A wrong address, a missed letter, and everything starts to fall apart. This will have potentially devastating health consequences.

When will this happen?

HHS has said it will provide 60 days’ notice to states before any termination or expiration of the PHE — and they have yet to do so. It also seems incredibly unlikely that they would announce an end date for the PHE before the midterm elections, as that would be a major self-inflicted political wound. So there’s a good chance we’ll be safe until at least January 2023 – but extensions beyond that seem less certain.

What are states doing to prepare?

CMS has released a series of guidelines over the past year to help states prepare for the end of PHE and minimize churn, another word for when people lose coverage. Some of these guidelines have included ways to work with managed care plans, which provide benefits to more than 70% of Medicaid enrollees, obtain up-to-date beneficiary contact information, and methods for raising awareness and support for enrollees during redetermination. treat.

However, the end of PHE and the Medicaid review process will largely be a state by state history. Georgetown University’s Center for Children and Families has been tracking how states are preparing for the outcome process. Not surprisingly, there are considerable variations between state plans, outreach efforts, and the types of information available to people seeking to renew their coverage. For example, less than half of all states have a publicly available plan for how the redetermination process will unfold. Although CMS has encouraged states to develop plans, they are not required to submit their plans to CMS and there is no public reporting requirement.

Who will be hurt the most?

If you dig into the HHS report, you’ll see that the opt-out cliff will likely be a disaster for health equity – as if the inequalities of the pandemic itself were not enough. A majority of those expected to lose coverage are non-white and/or Latinx, accounting for 52% of those who lose coverage due to eligibility changes and 61% of those who lose coverage due to administrative burdens. Projections show that only 17% of non-Latinx white people will be inappropriately unenrolled, compared to 40% of non-Latinx black people, 51% of Asian, Hawaiian, and Pacific Islander Americans, and 64% of Latinx people — a very grim picture. This represents a disproportionate burden of losing coverage, when still eligible, among those already bearing the inequitable burden of the pandemic and systemic racism more generally.

Another key population at risk are older adults and people with disabilities who have Medicaid coverage, or those who are not in the Modified Adjusted Gross Income (MAGI) population. Under the Affordable Care Act, states are required to re-determine renewal eligibility using available data. This process, known as ex parte renewal, saves registrants from having to respond to costly and potentially missing re-registration forms and notifications. Despite federal requirements, not all states attempt ex parte renewals for older adults and people with disabilities who have Medicaid coverage, or those who are not eligible based on income. Excluding these groups from the ex parte process has important implications for health equity, leaving already vulnerable groups more exposed and at risk of having their coverage inappropriately terminated.

What can be done?

There are ways to mitigate some of this loss of coverage and ensure people have continued access to care. HHS recently released a proposed rule that would simplify applying for Medicaid by shifting more of the burden of the application and renewal processes onto the government, as opposed to those trying to enroll or renew coverage. We could also change the rules to allow states to use more data, such as information collected to verify eligibility for the Supplemental Nutrition Assistance Program (SNAP), to make renewal decisions, rather than relying as much on income. The Biden administration has also made significant investments in navigator organizations, which can help those no longer eligible to transition from Medicaid to market coverage. Additionally, states should use this opportunity to determine the most effective ways to reach Medicaid enrollees by partnering with researchers to test different communication methods surrounding renewals and redeterminations.

As the federal government and state Medicaid agencies continue to prepare for the end of PHE, it is critical that they consider who these cumbersome processes will affect most and how to improve them to keep people from falling through the cracks. . More sick Americans without access to care is the last thing we need.

Paul Shafer, PhD, is an assistant professor in the Department of Health Law, Policy, and Management at Boston University. Gabriella Aboulafia is an MPP candidate at Harvard University.


Research for this coin was supported by Arnold Ventures. Shafer has received research funding over the past 12 months from the Robert Wood Johnson Foundation, The Commonwealth Fund, Arnold Ventures and Renova Health. He is also a researcher at the VA Boston Healthcare System under contract with the Boston University School of Public Health.

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