NYAPRS Note: Many states are fully underway with the Medicaid Redetermination process now that the national emergency, and the special temporary provisions that came with it, has officially ended. One of these provisions was expanded eligibility for Medicaid coverage. With state Medicaid eligibility reverting to normal requirements, many people face the possibility of losing Medicaid coverage, even if they are still eligible. Some states are taking very different approaches to redetermination, the process by which current enrollees get their eligibility reviewed to continue receiving coverage, with drastically different results. Some states, like Arkansas, seem to be quickly purging their Medicaid enrollments, with many losing coverage because of procedural issues, like not sending in letters in time. This unnecessary loss of needed health coverage is extremely concerning for our community. We will be monitoring the redetermination process, especially here in New York, and will share any important information. See below for two deeper analyses of the issues with Medicaid Unwinding.
Millions at Risk While Medicaid “Unwinds” Beneficiaries
By Phyllis Vine, PhD | Psychology Today | June 26, 2023
Those affected may have disabilities, mental illness, or substance use disorder.
Unwinding seems a neutral enough term in everyday conversation. It brings to mind images of letting a yo-yo drop, undoing knitting stitches, or gently unknotting a child’s tangled hair. In the context of practices currently underway to dis-enroll children and adults from Medicaid, it seems darker.
Unwinding is tied to states that are adjusting enrollment for people with Medicaid or Children’s Health Insurance Program (CHIP). It was written into the Families First Coronavirus Response Act in 2020, a federal response to the public health crisis of COVID-19.
An Effective Law
The Families First Coronavirus Response Act was intended only as a temporary backstop. It guaranteed two years of continuous enrollment while it paused the normal reapplication process, halted terminations, and waived income-based eligibility. A six-month window for a review of eligibility was written into the law upon expiration on March 31.
The law was so effective that Medicaid’s safety net grew by 30 percent, to 95 million people. And millions now require re-evaluation. Roughly 40 percent of Medicaid enrollees have a behavioral health condition or substance use disorder and are now at risk for termination. So, too, are children receiving CHIP, veterans, and 10 million people with a disability. They approach what the Kaiser Family Foundation (KFF) calls a coverage cliff.
Even for recipients who are later reinstated, short-term coverage gaps threaten management of conditions such as diabetes, heart disease, and behavioral health or substance use disorders. They undermine preventive care.
Partisan Conflicts
Unwinding Medicaid comports with cost-cutting goals. This has been a partisan priority since the 1980s when President Ronald Reagan (1981–1989) tried to rewrite the social contract using the federal budget as the tool. Just two months into office, he proposed cutting people with mental illness and/or disabilities from Social Security Disability Insurance, something contemporaries questioned for its fairness. Another of the cost-cutting initiatives questioned raising the retirement age.
Since then, dismantling Medicaid has been a Republican priority. More than 50 attempts to repeal the Affordable Care Act (ACA), which delivered Medicaid’s robust expansion, have failed. The most recent demonstration of the political polarities about Medicaid came to light during the debates over raising the debt ceiling.
Unwinding Underway
Since April 1, states have been “unwinding” to gut Medicaid recipients, some more vigorously than others. In Missouri, it’s up to 200,000 adults; in Oregon, it’s as many as 300,000 adults; California estimates that two million of the 15 million people receiving Medicaid could lose coverage. In Arizona, 2.4 million people will be reassessed. Utah expects the review process to take about a year, during which time everybody will remain enrolled.
KFF reports that already 1.5 million people in 21 states have been removed.
In Arkansas, Republican Governor Sarah Huckabee Sanders invoked tropes when she opined that unwinding helps people move from “government dependency to a lifetime of prosperity.” For people who are poor despite working more than one job, the “lifetime of prosperity” seems an illusion and market-based solutions unrealistic.
The Arkansas Department of Human Services was more straightforward when it said unwinding was “protecting taxpayers by removing ineligible clients.” With an increase in the Arkansas minimum wage to $11 an hour, officials expect more people to become ineligible.
In February, Arkansas added a requirement requiring Medicaid beneficiaries to work, attend school, or volunteer locally. The Obama Administration had refused a similar measure when it originally approved Medicaid expansion in Arkansas.
The Arkansas Democratic Party opposes the work requirement and calls it “mean-spirited.” They question Sanders’ efforts, claiming she will “undo progress” for 300,000 people, about one-quarter of the eligible recipients.
Obstacles to eligibility
Procedural shortcomings top the list for why people become ineligible. Some have submitted incomplete forms, others have moved and have a new address, still others have trouble with digital access. Some haven’t re-applied for enrollment. A survey of the KFF reports that many didn’t know they needed to reapply.
Some who are removed might issue appeals and be able to re-enroll. The process is called “churning,” and has led to chaos and misinformation in households where only a single person was re-enrolled even if other adults and children were eligible.
There is an additional hurdle for people who live in one of the 10 states (Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, or Wyoming) which haven’t expanded Medicaid. About one-quarter have behavioral health conditions. The Center on Budget and Policy Priorities estimates that in 2021 roughly 60 percent were Black, Latino, or Asian. Half were employed in low-wage jobs, making it more difficult to obtain insurance through conventional work or market-based insurance.
The Rush to Cut
Republican governors in seven states (Arkansas, Idaho, Iowa, New Hampshire, Ohio, South Dakota, and West Virginia) have opted to compress the process into the original window of six months. The Biden administration expanded this to 12 months, hoping for a more deliberate process. There are reports that the president is angry that the process is being rushed.
In a letter to governors, Health and Human Services Secretary Secretary Xavier Becerra wrote, “I am deeply concerned with the number of people unnecessarily losing coverage, especially those who appear to have lost coverage for avoidable reasons that State Medicaid offices have the power to prevent or mitigate.”
When the clamor rushing Medicaid decisions lines up along partisan lines, one has to wonder why? And how unwinding shrinks Medicaid’s vigor for the nation’s most vulnerable citizens with mental health and substance use disorders.
Millions at Risk While Medicaid “Unwinds” Beneficiaries | Psychology Today
Quiet Crisis of Medicaid Redeterminations and Disenrollments Demands Attention
By Ron Manderscheid, PhD | Behavioral Health Executive | June 27, 2023
It is well known that people with behavioral health conditions can have great difficulty enrolling in health insurance and remaining enrolled. That is why the current enrollment redeterminations mandated for state Medicaid programs are so concerning to the field. Kaiser Family Foundation has estimated that between 8 and 24 million persons could be disenrolled from Medicaid as part of this. Assuming conservatively that overall prevalence rates for behavioral conditions (25% annual prevalence for adults) apply to this group, that would mean between 2 and 6 million persons with behavioral health conditions could be disenrolled in the coming months. These are shocking numbers.
At the outset of the COVID-19 pandemic, the Families First Coronavirus Response Act required that state Medicaid Programs keep people enrolled continuously, and that the federal government would provide states with enhanced federal Medicaid funding to help cover related costs. This resulted in an expansion of the Medicaid population from about 72 million to 95 million enrollees nationally between 2020 and the present. The Consolidated Appropriations Act of 2022 ended this continuous enrollment requirement on March 31, 2023, and initiated a phase down of federal Medicaid matching funds by December 2023.
All states began the mandated redetermination process between February and April this year. Informal reports from the field suggest that as many as 1 million enrollees already have been removed from the rolls. In this process, the state Medicaid agency reviews beneficiary income, household size, and other eligibility criteria using electronic data sources. Sometimes the beneficiary is asked for additional information. Even if the beneficiary still qualifies for Medicaid, it is essential that he or she participate in this redetermination process. If not, the state will disenroll the beneficiary despite being qualified.
It seems clear that certain groups will have greater difficulty in maintaining Medicaid coverage in the redetermination process, including persons with disabilities, such as mental health, substance use, and intellectual and developmental disability conditions, those who are older, those who have changed their physical address, immigrants, and persons with limited English proficiency. Even if they remain eligible, they will be at increased risk of losing coverage or experiencing a coverage gap due to difficulties in negotiating renewal requirements.
Similar issues will occur for these individuals when they are determined to no longer be Medicaid eligible. They will have increased difficulty in applying for health insurance for low-income individuals through the state health insurance marketplaces set up under the Affordable Care Act, or in applying through their employer for work-based health insurance.
Although the Centers for Medicare and Medicaid Services already has issued alerts to Medicaid recipients about this redetermination process, it is truly clear that the behavioral health field will need to provide support and navigation guidance to Medicaid enrollees with behavioral health conditions. Such efforts are needed right now on 2 fronts: to help those who remain eligible for Medicaid to re-enroll and to help those who no longer are eligible for Medicaid to enroll in other public or private health insurance.
We have known for an exceptionally long time that the discontinuous enrollment of beneficiaries in Medicaid (called “churn”) does lead to much greater difficulty in accessing health and behavioral health services. That is why we always have advocated for continuous enrollment on a predictable cycle, e.g., 5 years, with a much longer period for transition when a beneficiary is no longer eligible. These principles clearly are being violated in the current mandatory redetermination process.
Some have called the current redetermination process a “quiet crisis” that is receiving extraordinarily little political or media attention. Despite this, it will be necessary for us to mobilize the field to provide the support and navigation our Medicaid clients need at this time. The need is urgent.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.