Columnist Al Norman: The ‘unwinding’ of Medicaid: A quiet health emergency


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Published: 08-23-2023 7:34 PM

On May 11, the federal government announced the end of the COVID-19 Public Health Emergency (PHE). That announcement — which should have been good news for millions of Americans, instead turned into “a quiet health care emergency,” according to one health care advocacy group, as millions of low-income people faced termination of their Medicaid health care coverage.

Here’s why:

People on Medicaid have to re-enroll every year. But on March 18, 2020, then-President Donald Trump signed into law the Families First Corona Virus Response Act. This law gave increased Medicaid funding of 6.2% to states if they provided “continuous coverage” for people on Medicaid for as long as the COVID emergency existed. State Medicaid agencies were not allowed to unenroll anyone from Medicaid unless they asked to be unenrolled, moved out of state, or died.

But in December 2022, Congress passed the Consolidated Appropriations Act, which “delinked” the Medicaid continuing coverage requirement from the public health emergency, allowing states to resume Medicaid terminations. The term “unwinding” was coined to describe the process of terminating continuous coverage.

Before terminating people, Medicaid agencies were required to attempt to complete an “automated renewal” based on information already available to them — such as wage information or SNAP (food stamp) files. Agencies were also required to send renewal notices to enrollees, and to process their cases if they responded. If a person was no longer eligible, the state would notify them that their coverage was ending.

If a recipient moved, or could not be found, or simply did not understand what they had to do to respond, they were terminated from Medicaid. The feds gave states an unwinding period of up to 12 months to start renewals for all enrollees, and 14 months to complete them.

Medicaid “unwinding” did not begin all at once. Five states began terminating people as of April 1, 2023; another 15 states set a date of May 1. All other states but one began ending Medicaid coverage in June or July of this year. States will continue to receive enhanced federal matching funds until the end of 2023, as long as they make “good faith efforts” to contact enrollees before their coverage is terminated, based on returned mail.

Many states were found not to be in full compliance with these renewal requirements. Many people lost their health care coverage for “procedural reasons.” If a state fails to comply with these unwinding rules, and does not submit a corrective action plan, the feds can require a state to pause all coverage terminations made due to procedural reasons, and to pay financial penalties.

The “unwinding” has turned into a national health care emergency. According to a report released by the Kaiser Family Foundation in late April, during continuous coverage (February 2020 to March 2023) Medicaid enrollment grew by an estimated 20 million people, and America’s number of citizens without health insurance dropped to the lowest level on record by the start of 2022. Kaiser estimates that “17 million people could lose Medicaid coverage — including some who are no longer eligible and others who are still eligible but face administrative barriers to renewal.”

Kaiser updated its figures in August to report that “38% of renewals end up disenrolled,” and the total people dropped could soar to 35 million.

Medicaid is not an easy program to renew once a year. In Massachusetts, you have to wade through a 38-page application form that requires everyone in your household to complete 34 questions and provide documentation of your federal tax returns, if you file; proof of your citizenship or immigration status; employer/income info (pay stub, wage statements) for everyone in your household; info on any job-related income or other health reimbursement arrangements; income deductions; and recent medical bills.

It can take hours to complete, even with help from an advocate. If you don’t have a copy machine or fax at home, you can lose coverage.

The media has reported that state Medicaid call centers have been inundated with questions from people needing help to apply, and one-third of states have been warned by Medicaid officials that their lengthy call center wait times “may be causing people to hang up— and give up.” In one state, more than half the callers abandoned their calls — and terminated their health care as a result.

Readers are urged to call their members of Congress at 202-224-3121, and urge them to enforce “corrective action” plans in states to prevent Medicaid terminations due to procedural causes, and encourage states to approve redeterminations under “presumptive eligibility” rules whenever possible.

Al Norman of Greenfield worked in the elder home care field in Massachusetts for three decades. He writes a regular column for the Recorder.