States Denying Medicaid Coverage after the April 1st Cutoff

This is a nice writeup on what is occurring in states which have enrolled multiples of their citizens into Medicaid due to various initiatives and the ACA. There has been a rollback of ACA insurance levels with the Silver plan having an actuary of 94%. People making up to 200% FPL pay little or nothing. Mediciad eligibility was increased to 150% FPL. This was a good initiative by the Biden administration and the correct action to take during a Pandemic. It would also be the correct action to maintain going forward.

Except elements of the politicians and the population seem to believe the denial of healthcare access will gain them the actions they wish others to have. Except it doesn’t. Too many other factors come into play impacting people.

I rewrote segments of this commentary adding more information to it.

Fifteen million people could lose Medicaid in the next year,, Ryan Levi & Dan Gorenstein

There are estimates of 15 million people losing Medicaid coverage starting April 1 as states rollback Medicaid eligibility. For the first time in three years, states will begin removing people from the low-income health insurance program.

In March 2020, Congress banned states from removing people from Medicaid. Instead they gave more federal funding for state Medicaid programs during the pandemic. Medicaid enrollment is usually tied to people’s incomes, and individuals normally have to regularly prove they still qualify in what’s known as a redetermination. (In the 39 states and Washington, D.C., that have expanded Medicaid, a family of four has to make less than $40,000 to qualify. In non-expansion states, the cutoff is even lower.)

With redeterminations paused, Medicaid enrollment nationwide has grown from 71 million in February 2020 to an estimated 95 million in March 2023. Research by the Robert Wood Johnson foundation shows Medicaid coverage is associated with better access to care, more financial security, better health, and lower mortality. During the pandemic, beneficiaries were able to enjoy these benefits without worrying about confirming their eligibility.

In December, Congress voted to let states restart the process of clearing their rolls on April 1, in what is sometimes referred to as “unwinding.” Federal lawmakers are giving states 14 months to redetermine the millions of people’s eligibility. An unprecedented task made even difficult by serious staffing and experience shortages in many Medicaid offices.

Health policy researcher at the University of Minnesota and Tradeoffs Senior Research Advisor Sayeh Nikpay . . .

“It’s going to be a big lift. States have never had to do this many redeterminations this quickly before, and there’s a lot of uncertainty about what will happen.”

We asked Sayeh Nikpay to pick out a few relevant studies to help us understand what is happening and how states and employers could keep more people insured. Here are three she identified as particularly helpful.

Two categories of people will lose coverage

The Office of the Assistant Secretary for Planning and Evaluation (ASPE), which provides research for the U.S. Department of Health and Human Services, released a report August 2022. The report estimates 15 million people will lose Medicaid coverage as a result of the unwinding. (The estimate is similar to another analysis by the independent Urban Institute.)

ASPE breaks the 15 million people into two groups.

  • In the first group are people who make too much money to qualify for Medicaid. ASPE estimates there are about 8 million people in this category. They should be able to get insurance through work or the Affordable Care Act (ACA) exchanges.
  • In the second group, there are approximately 7 million people which ASPE estimates are still eligible. They will lose coverage due to “administrative churn.” Administrative churn happens when the Medicaid office can’t get in touch with someone to confirm their eligibility. It can occur if a person has moved, changed their phone number, or if they’re unable to make an in-person appointment because of work or child care responsibilities. (The Urban Institute projects about 4 million people will be in this group.)

These two groups represent a key tension to the unwinding process: States want to shed people who make too much money, but officials also know eligible people often lose coverage during redeterminations. The danger of losing coverage increases given the scale and speed of this process.

Making the switch from Medicaid to private insurance

This next paper reviews the first group. The approximate 8 million people moving from Medicaid to private coverage. Specifically, we review the approximate 4 million who may get coverage through the Affordable Care Act (ACA) exchanges. An Assistant Professor of Health Policy at Harvard, Adrianna McIntyre wrote in a JAMA Health Forum (October 2022) about the most effective ways to move people from Medicaid to private ACA healthcare plans.

There’s limited data on this, but based on the few studies available, Prof. Adrianna McIntyre found 3 to 5 percent of people who leave Medicaid end up getting an ACA plan. Many policymakers are expecting the ACA exchanges to provide a life preserver to millions of people losing Medicaid coverage. The research cited by McIntyre shows getting people into these plans is not a guarantee. It may take a focused effort by states.

Professor McIntyre’s review cites several randomized controlled trials where states tested different ways of increasing enrollment in ACA plans. The studies found simple reminders from a state such as physical letters, emails and phone calls often helps, It can boost sign-ups anywhere from 7 to 16 percent.

But what really seems to make a difference are reminders plus connecting people to someone who can get them signed up while they are on the phone. In one of the trials published in 2022, people in California who got a reminder email and/or a call connecting them to enrollment assistance were almost 50 percent more likely to sign up for a plan. Such extra effort can be costly. It also may not be a priority or financially feasible for some states.

Professor McIntyre’s review did not include any research on what employers can do to help their workers transition from Medicaid to work-based coverage. Based on the studies Professor McIntyre cited, Research Advisor Sayeh Nikpay said she thinks it’s a good idea for employers to make sure people know Medicaid could be going away and provide as much help as possible in getting new coverage.

Making it easier to stay on Medicaid can have other benefits

The final study looks at the second group of people expected to lose Medicaid coverage. The 7 million people who may lose coverage due to administrative churn even though they are still eligible.

Some states have tried to limit churn, and researchers at the RAND Corporation evaluated New York’s effort. Starting in 2014, New York allowed people to stay on Medicaid without any redeterminations for 12 months once enrolled.

In addition to keeping more people on Medicaid for longer, researchers found that after this policy was in place, hospital admissions and monthly costs per beneficiary decreased. The researchers can’t say whether the continuous enrollment policy directly caused these improved outcomes or not. The findings suggest avoiding administrative churn can help people stay covered without ballooning costs.

Sayeh Nikpay said of the findings . . .

“It seems reasonable to me. That making it easier to stay on Medicaid, even outside of a global pandemic, could benefit people’s health given what we know about how Medicaid affects people.”

Access to healthcare is a factor in people being able to be employed. As sickly employees are more likely to perform poorly in their jobs.

This story comes from the health policy podcast Tradeoffs, The Treacherous Transition Awaiting Millions Losing Their Medicaid, Tradeoffs. Tradeoffs is a partner of Side Effects Public Media. Dan Gorenstein is Tradeoffs’ executive editor. Ryan Levi is a reporter/producer for the show, which ran this story on March 30, 2023.