Tag: Medicaid

Millions of Americans could lose Medicaid insurance as the pandemic winds down

Perhaps the greatest success of the American health care system these last few benighted years is this surprising fact: The uninsured rate has reached a historic low of about 8 percent.

That’s thanks in part to the pandemic — or, more precisely, the slew of emergency provisions that the government enacted in response to the Covid crisis.

One policy was likely the single largest factor. Over the past three years, under an emergency pandemic measure, states have stopped double-checking if people who are enrolled in Medicaid are still eligible for its coverage. If you were enrolled in Medicaid in March 2020, or if you became eligible at any point during the pandemic, you have remained eligible the entire time no matter what, even if your income later went up.

But in April, that will end — states will be re-checking every Medicaid enrollee’s eligibility, an enormous administrative undertaking that will put health insurance coverage for millions of Americans at risk.

The Biden administration estimates upward of 15 million people — one-sixth of the roughly 90 million Americans currently receiving Medicaid benefits — could lose coverage, a finding that independent analysts pretty much agree with. Those are coverage losses tantamount to a major economic downturn: By comparison, from 2007 to 2009, amid the worst economic downturn of most Americans’ lifetimes, an estimated 9 million Americans lost their insurance.

Some will lose coverage because they are no longer eligible due to a change in income or circumstance, such as a child turning 18. States are supposed to direct these people toward other insurance options, such as the Affordable Care Act marketplaces.

But many of the people who end up losing their benefits — even most, according to some projections — could be people who are actually still eligible for Medicaid but slip between the cracks of the system. People who have recently moved are one particular concern, as are children and people with disabilities.

For people who watch health policy closely, the coming “redetermination” process is one of the biggest stories of the year, with major ramifications for Americans’ health.

A lot of people are going to lose coverage no matter what. That is inevitable. The emergency “continuous coverage” provision, which cost nearly $150 billion over the past three years, was never going to be indefinite. The US health system is not set up to provide that many people, some of whom are no longer eligible for the program, with indefinite health benefits, unless they are old enough to qualify for Medicare.

But the goal, according to people who advise and advocate for people on Medicaid in states across the country, should be to minimize the number of Americans who lose their Medicaid benefits even if they are still eligible for them, and to make sure that the people who no longer qualify for Medicaid get other coverage.

Don’t let too many people fall through the cracks. Otherwise, the coverage gains of the past few years could be quickly eroded.

“If people lose Medicaid, whether they’re ineligible or remain eligible for Medicaid, and they’re not connected with another form of insurance, that’s potentially devastating for individuals,” Emma Morris, a policy analyst at the Oklahoma Policy Institute, told me. “This is a really pivotal point.”

This year’s coverage losses could be particularly dramatic. But they’re also a symptom of a bigger, more persistent problem that predated the pandemic: People cycle on and off Medicaid coverage all the time, including for reasons as mundane as paperwork. It’s a problem that, historically, many states have shown little interest in solving, and one that is now reemerging with a vengeance.

The end of Medicaid emergency continuous coverage, explained

The task in front of public officials is enormous: check the eligibility of every single one of the 90 million people currently on Medicaid to confirm they still meet the criteria for their benefits. And if they don’t happen to reach someone because that person moved, or they think a notice from the state is junk mail? That person will find themselves out of luck — and out of Medicaid.

Preventing that worst-case scenario will depend on states getting the word out early and often and using all of the tools available to them to reach people. Whether they will actually do that is already creating some concern. Congress has given states up to 12 months to complete the redetermination process. But in Texas, where as many as 1 million people may lose coverage, state officials have said they want to finish it in eight months, for reasons that are not clear.

“That raises a concern of trying to do this fairly complex job in a shortened timeline and the risk that might lead to adverse redetermination outcomes for people that that still are entitled to being in Medicaid,” Jason Terk, a physician and chair of the Texas Public Health Coalition, said.

In an ideal scenario, many beneficiaries won’t have to do anything to affirm their Medicaid eligibility. States can check existing data sources to verify a person’s income. If they are still eligible, they will keep their benefits. If they are not, the state should let them know what their insurance options are. (We’ll come back to that.)

The problem is these automatic checks are something a lot of states were terrible at doing prior to the pandemic. Almost all states say they conduct what are known as ex parte renewals, meaning they use existing public data to verify people’s eligibility without the person having to do anything. Ex parte renewals were supposed to be mandatory under the Affordable Care Act. But, according to Jen Wagner at the Center on Budget and Policy Priorities, enforcement has been lax: A few states don’t do them at all, and 20 of them said they completed less than half of their renewals this way. Some states, including Texas, have decided not to adopt policies that make ex parte renewals easier, such as assuming people who are eligible for SNAP, or food stamps, are also eligible for Medicaid.

Now states’ ability to perform those tasks is crucial. Most states say their redetermination plans start with ex parte renewals, which will test the effectiveness of their databases and IT systems. And many Medicaid offices are beginning this process understaffed: One in five jobs posted at state Medicaid offices were unfilled, according to the National Association of Medicaid Directors. In some states, nearly half of the jobs, more than 40 percent, were unfilled.

“We’re seeing states struggling right now to keep up now, when you’re not doing renewals,” Wagner said.

The first way states are trying to minimize risk is by starting the process with certain groups of people who may be at less risk if they lose coverage, such as those who have never filed a claim while enrolled in Medicaid; for those recipients, the possibility of disrupting medical care seems lower. In states like Oklahoma, Missouri, North Carolina, and Florida, where I interviewed patient advocates and state Medicaid officials to get a better sense of states’ preparation, the plan was usually to save more vulnerable populations — older people, people with disabilities, and children — for the later phases.

For people whose eligibility cannot be confirmed via a public database, states will have to do it manually. That will mean sending out mail and other forms of communication to ask beneficiaries to send in information so their eligibility can be verified.

That can be a difficult task. People move, some frequently. They ignore mail. They may not know this is happening in the first place. Most states allow people to report eligibility details or change their contact info on their websites or over the phone, but not all do — and those services, such as a call center, have to be adequately staffed. Otherwise, problems can arise and people may give up rather than put up with a hassle.

In Florida and Texas, two states worth watching closely given their large size and right-leaning politics, Republican leaders have not appeared very engaged on the issue, even as doctors and activists in those states credit the state health agencies with taking it seriously.

“The political leadership is not particularly enamored with or concerned about necessarily enhancing Medicaid policy here in the state of Texas,” Terk said. “I would hope, and I would try to be optimistic, that the governor’s office would be more forceful in his messaging. … It would be helpful if that were to happen. But I’m not sure that it’s reasonable to expect that.”

There are myriad ways administrative friction leads to people losing benefits when they shouldn’t. States have to be invested in preventing it. In states like Missouri and Oklahoma, top elected officials have been actively fighting against the implementation of Medicaid expansion, which made many low-income adults newly eligible for the program; now many of the people who became eligible through the expansion in the past few years will have their eligibility checked for the first time. Policy analysts worry some of those people could lose coverage simply because they aren’t familiar with the process.

Another way people could lose coverage in the coming months is if they are legitimately no longer eligible for Medicaid but fail to get enrolled in a different insurance plan.

States could make a big difference in preventing that, by directing people to the ACA marketplaces (where they may qualify for government assistance) and the navigators who receive federal funding to help people sort their marketplace options and sign up.

Medicaid offices across the country have been planning for this for months. But it’s not clear some states are doing everything they can on to make sure people who are no longer eligible are enrolled in a new health plan In Florida’s redetermination plan, for example, the actual mechanisms for directing people to their other coverage options are left vague and navigators are not mentioned at all.

“A lot of these plans sound excellent. The question is, what do they look like in implementation?” Alison Yager, executive director of Florida Health Justice, told me. “There are invariably going to be challenges. This is too huge for there not to be challenges.”

According to the Georgetown Center for Children and Families, nine states have not even posted their public plan for this Medicaid unwinding. A similar number have not shared any kind of communications toolkit, which could be useful to the advocates and providers who will be on the front lines of educating people about the situation. (Here is an example from the state of Texas.)

Some people may have no viable option for coverage at all, if they’ve had a change in circumstance that renders them ineligible (such as a child turning 18) but they live in a state that hasn’t expanded Medicaid under the ACA nor do they have a high enough income to qualify for subsidies to purchase private insurance.

Florida is one of those non-expansion states. One family there, who shared their story with Florida Health Justice, has three members who all need regular monitoring and check-ups because of complex medical conditions. They were supposed to lose their Medicaid coverage in 2020, when their son turned 18, but that was postponed through the continuous coverage provision. When that policy ends, they may become uninsured because Florida has not expanded Medicaid under the ACA.

It all adds up to a dramatic and sudden US health policy problem that has laid dormant for the past three years: churn.

The problem of Medicaid churn remains

It is an absurdity of the American health system, compared to those of other developed countries, that millions of vulnerable people could end up becoming uninsured in a matter of months. But even in normal times, because of how our health system is set up, people with low incomes shift frequently between different insurance coverage, going from Medicaid to ACA insurance subsidized by the federal government or not having any insurance at all.

It’s called “churn,” and it has long been recognized as a problem. In 2018, about 10 percent of Medicaid enrollees cycled on and off the program within a year.

Sometimes, people can simply have a few months where they pick up extra work hours, boosting their income to the point they are no longer eligible, and they lose coverage. (Eligibility checks vary across states in normal times.) The next month, their earnings may drop back down, making them eligible once again — but then they have to sign back up.

It adds to the workload for those understaffed Medicaid offices and it can disrupt health care for the patients too. People don’t fill prescriptions when they have to pay more money out of pocket. They skip doctor’s appointments and other vital services.

Now, after the three-year pause on redeterminations eliminated that problem, the end of the emergency coverage will bring it back.

States could be doing more to prevent Medicaid churn — but, at least so far, they’re not. The low rate of ex parte renewals that automatically confirm eligibility was one way the US was coming up short pre-pandemic.

States are also not taking advantage of other optional policies that the federal government has made available. A state can, for example, extend coverage for a woman who becomes eligible during pregnancy through their first year after her child is born. Only three states have actually done so, according to the Georgetown Center for Children and Families.

A year of continuous coverage for kids is more common, and states such as Oregon and Washington have even approved multi-year continuous eligibility for children. On the other hand, more than a dozen states have not adopted that policy either and a number of others have conditions that limit their effectiveness.

Congress has recently added some new requirements to address the problem for the longer term, including that all states provide children with 12 months of continuous coverage starting next year. That should help. But it won’t eliminate the problem entirely. It will come back again to how well states perform in checking and re-checking people’s eligibility, now and in the future, and whether they are being held accountable when they fall short.

There has been more sustained interest in the problem of Medicaid churn with the end of the emergency coverage provision approaching. But it remains to be seen how long it will last. A reversion to the pre-pandemic normal would put beneficiaries at a higher risk going forward of losing their coverage than they should. Research has routinely shown people have more access to health care, use more health care, and self-report better health when they are enrolled in Medicaid. That is what people are losing when they lose their benefits.

Churn is inevitable in the multi-payer structure that the US has set up to finance its health care. But we could be handling it better. The massive redetermination process will be an immense test, forcing states to re-check the eligibility of every single beneficiary. But even once it’s over, individual patients will still face the risk of losing coverage when they perhaps should not. The problems churn creates are not going away.

“Churn doesn’t have to be what it is. Unwinding doesn’t have to be a disaster,” Wagner told me.

The stakes for the rest of 2023 are enormous, and Medicaid agencies have not always performed well in the past in making sure everybody who is eligible for Medicaid gets on it. Now, health coverage for millions of Americans hinges on their being able to get it right.

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Medicaid grew a lot during the pandemic. Soon, it will shrink again. : Shots

Medicaid grew a lot during the pandemic. Soon, it will shrink again. : Shots

George Mink Jr. is a health care outreach worker in Delaware County, Pa. He worries about what will happen when vaccines are no longer paid for by the federal government. (Kimberly Paynter/WHYY)

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George Mink Jr. is a health care outreach worker in Delaware County, Pa. He worries about what will happen when vaccines are no longer paid for by the federal government. (Kimberly Paynter/WHYY)

Kimberly Paynter/WHYY

Robert, who lives in Philadelphia, knows signing up for Medicaid can be tricky with his ADHD, so he brought his daughter along to help him fill out the paperwork.

“If we miss one little detail, they would reject you,” says Robert, who has had the government health insurance for people on low incomes in the past. “I usually get two applications, so if I mess up on one. I can do the other one.”

This time, with his daughter’s help, the application only took Robert a half hour. (NPR agreed to use Robert’s first name only because he has a medical condition he would like to keep private.)

Signing up for Medicaid correctly is about to become an important step for enrollees again after a three-year break from paperwork hurdles. In 2020, the federal government recognized that a pandemic would be a bad time for people to lose access to medical care, so it required states to keep people on Medicaid as long as the country was in a public health emergency. The pandemic continues and so has the public health emergency, most recently renewed on Jan. 11.

But the special Medicaid measure known as “continuous enrollment” will end on March 31, 2023 no matter what. It was part of the budget bill Congress passed in Dec. 2022. Even if the public health emergency is renewed in April, states will begin to make people on Medicaid sign up again to renew their coverage. And that means between 5 and 14 million Americans could lose their Medicaid coverage, according to the Kaiser Family Foundation, the nonpartisan health policy organization..

The federal Department of Health and Human Services expects 6.8 million people to lose their coverage even though they are still eligible, based on historical trends looking at paperwork and other administrative hurdles. Pre-pandemic, some states made signing up for and re-enrolling in Medicaid very difficult to keep people off the rolls.

In the three pandemic years, the number of Americans on Medicaid and CHIP – the Children’s Health Insurance Program – swelled to 90.9 million, an increase of almost 20 million.

Jenn Lydic is the director of social services and community engagement at the Public Health Management Corporation, a nonprofit that runs six health centers in Philadelphia. She says the reprieve from renewal paperwork “allowed for a continuity that I think has really been lifesaving for a lot of folks.”

“I know so many patients who have now been able to really finally get ahead of a lot of their health conditions,” Lydic says.

Research shows that disruptions in Medicaid coverage can lead to delayed care, less preventative care, and higher health care costs associated with not managing chronic conditions like diabetes and substance-use disorder.

Philadelphia Health Commissioner Cheryl Bettigole worked in city health centers for years. She said the continuous Medicaid enrollment and pandemic measures like free access to COVID-19 tests and treatments have been a big advance. She would like to see some of that last.

“There was this moment with the pandemic in which we recognized that it was really important for everybody to have access to care. And we’ve somehow changed our minds about that,” says Bettigole. “If we were to have a newer, better vaccine that lasts longer, we would want everyone to get that. We recognized it for a moment, for a single condition, and now we’re kind of walking back from that. I do think that’s a pity.”

The boosted Medicaid rolls mean the country has a historically high rate of people with insurance at 92{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}. That rate is likely to erode as Medicaid winnows down again. States do have some discretion on how they re-start the sign up process. It could take a few months to a year. If a state finds someone to be no longer eligible for Medicaid, they won’t be cut off immediately, said Jennifer Tolbert, associate director for the program on Medicaid and the uninsured at the Kaiser Family Foundation. The Pennsylvania Department of Human Services said it will take a full year to do this and is working to make sure no one experiences a lapse in health coverage.

The federal government also increased Medicaid funding to the states in 2020, and that increased funding won’t start phasing out until the end of 2023. Tolbert added that the move to keep people enrolled on Medicaid continuously is truly unprecedented, but there will be some lasting changes from the pandemic.

For instance, Oregon will allow children who qualify for Medicaid to enroll at birth, and stay enrolled until age 6, without having to reapply. Washington, California, and New Mexico are considering similar policies as well.

Another concern is what happens when the federally-funded supply of COVID-19 vaccines and tests ends. Last August, the federal government announced they do not have more funds from Congress to pay for COVID-19 vaccines. In March 2022, the federal government stopped paying for tests for uninsured patients.

George Mink Jr. is a community activist for Health Educated, a nonprofit in Delaware County that has hosted vaccine clinics, health fairs, and webinars. He took advantage of free Covid testing and vaccines early in the pandemic. Mink said he might not have gotten tested if he had to have health insurance or pay for it himself. He has not had any serious health issues, but in 2020, a close family friend died from COVID-19. Mink and his family got tested and found out they were positive.

“Who knows what could have happened?’ he says. “We still would have been … infecting other people. It made a major difference.”

Mink is also up to date with his COVID-19 vaccinations, but worries about what will happen when the vaccines are no longer free: “What if in two months, we got a new variant coming and now I need a new booster, and now I can’t afford it?”

Dr. Kristin Motley, a pharmacist, founded Health Educated, an outreach organization in Delaware County, Pa. Flyers for the podcast she hosts with George Mink Jr. (Kimberly Paynter/WHYY)

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Dr. Kristin Motley, a pharmacist, founded Health Educated, an outreach organization in Delaware County, Pa. Flyers for the podcast she hosts with George Mink Jr. (Kimberly Paynter/WHYY)

Kimberly Paynter/WHYY

The health departments in Pennsylvania and Delaware say they plan to keep providing free tests and vaccines for the foreseeable future, and that the federal government has yet to say when the free vaccine supply will be cut off.

Pharmacist Kristin Motley, the founder of the Health Educated nonprofit where Mink works, will be sorry to see the free vaccines go.

“It allowed us to go into the community, wherever people were and to say, you don’t have to register, you don’t have to bring I.D., you don’t have to bring insurance. You just come,” she says. “That was really nice to be able to help people in that way with no red tape, no bureaucracy. It was so seamless.”

Medicaid: What to Watch in 2023

As 2023 kicks off, a number of issues are at play that could affect coverage and financing under Medicaid, the primary program providing comprehensive health and long-term care coverage to low-income Americans. The Consolidated Appropriations Act, passed in December 2022, ends the Medicaid continuous enrollment provision on March 31, 2023 with a phase-down in enhanced federal matching funds. The unwinding of this provision, as well as the trajectory of the pandemic and the economy, will have implications for Medicaid enrollees, providers, managed care plans, and the states that operate these programs. A divided Congress will make it difficult to pass federal legislation, and while the Administration is expected to continue to use existing authority to improve coverage, access, and health equity, limited action at the federal level will push even more policy focus to the states. The first glimpse of state policy priorities will be revealed in Governors’ state of the state addresses and proposed budgets. Within this context, this issue brief examines key issues to watch in Medicaid in 2023.

Medicaid Coverage and Financing

The Medicaid continuous enrollment provision in place during the pandemic has increased enrollment and reduced the uninsured rate, but will end in March 2023. Provisions in the Families First Coronavirus Response Act (FFCRA) required states to ensure continuous enrollment in Medicaid in exchange for enhanced federal matching funds during the Public Health Emergency (PHE). Largely due to these policies, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) grew to 91 million in September 2022, an increase of 27.9{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} from February 2020 (prior to the pandemic). KFF estimates that through federal fiscal year 2022, states received more than double the amount in federal fiscal relief relative to the costs of enrollment due to the continuous enrollment provision, with some variation across states. The Consolidated Appropriations Act ends the continuous enrollment provision on March 31, 2023, and phases down the enhanced federal Medicaid matching funds through December 2023. States can resume disenrollments beginning April 1 but must meet certain eligibility and reporting requirements to continue to be eligible for enhanced funding. An estimated 5 to 15 million people could lose Medicaid coverage during unwinding and how states manage the process could affect how many people are able to maintain coverage.

Debate about Medicaid expansion will shift back to the states. Democrats in Congress last year discussed a federal option to fill in the Medicaid coverage gap but ultimately did not pass it, and such an approach is now highly unlikely with divided control in Washington. The American Rescue Plan Act (ARPA) included a two-year fiscal incentive to encourage remaining “non-expansion” states to newly adopt the Affordable Care Act (ACA) Medicaid expansion. Over  2 million individuals living in the 11 states that have not adopted the (ACA Medicaid expansion fall into the “coverage gap”). These individuals do not qualify for Medicaid (as their income exceeds Medicaid eligibility limits in their respective states) but have incomes below poverty, making them ineligible for premium subsidies in the ACA Marketplace. A KFF analysis shows that all non-expansion states would see a net fiscal benefit from the ARPA incentive for two years if they adopt the expansion. The ARPA federal incentive reignited discussion around Medicaid expansion in a few non-expansion states during the last state legislative session. Notably, every state that has adopted expansion since 2019 has done so not through legislative or executive processes, but as a result of a successful ballot initiative. Most recently, South Dakota became the 40th state to expand Medicaid after voters approved a ballot question in November 2022. Although expansion ballot initiatives have been successful in all seven states where they have gone to voters (Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah), most of the remaining non-expansion states do not have ballot initiative processes. North Carolina may be the state most likely to expand Medicaid next given how far efforts advanced last year, with active efforts in Kansas and Wyoming as well.

Some states and the Administration are expected to continue to implement incremental policies to expand coverage. ARPA included an option, made permanent in the Consolidated Appropriations Act, to allow states to extend postpartum coverage from 60 days to 12 months. Under current law, after the 60 days of postpartum coverage, many people who qualify for pregnancy-related Medicaid  lose that coverage because Medicaid eligibility levels for parents are much lower than for pregnant people in most states, and especially in non-expansion states. As of January 2023, more than two-thirds of the states have taken steps to extend postpartum coverage. The Consolidated Appropriations Act also included a requirement for all states to implement 12 months of continuous coverage for children. In addition, Oregon received waiver approval to provide continuous eligibility for children from birth to age 6 and 2 years of continuous eligibility for all enrollees ages 6 and up, including adults; other states are seeking similar waivers for multi-year continuous eligibility. KFF analysis shows that for children, continuous eligibility policies help to provide coverage stability. Finally, the Administration released a proposed regulation designed to make it easier for individuals to obtain and retain coverage.

New state and federal attention to Medicaid financing could emerge in 2023. Medicaid financing is shared by the federal government and the states. Consequently, economic factors that affect state revenues including inflation, supply chain issues, and declining labor force participation rates, along with phase-down of the enhanced FMAP tied to the end of the continuous enrollment provision will have fiscal implications for states. In our annual state survey, states noted that inflation and workforce shortages were driving higher labor costs and pressure from providers for rate increases. Many states use reimbursement methodologies for some provider types, such as nursing facilities, that may automatically adjust for inflation. In addition, at the federal level the House of Representatives is likely to focus on measures to reduce the federal deficit and, while unlikely to pass in the Senate, proposals to limit federal spending for Medicaid could be debated again in Congress.

What to Watch:

  • What will happen to Medicaid enrollment during the unwinding of the continuous enrollment provision? How will changes vary across states? How many people losing Medicaid coverage will transition to other sources of insurance like the Affordable Care Act marketplaces, and what will happen to the number of uninsured?
  • Will any additional states implement Medicaid expansion or other coverage expansions like 12-month postpartum coverage?
  • How will administrative actions, including oversight of the unwinding of the continuous enrollment provision, waiver approvals, and new regulations contribute to changes in coverage?
  • How will broader economic factors, like inflation, affect state financing of Medicaid and will Congress debate broader proposals to cap federal Medicaid spending?

Access and Health Equity

Capitated managed care remains the predominant delivery system for Medicaid in most states. More than three-quarters of states that contract with MCOs (35 of 41) reported that 75{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} or more of their Medicaid beneficiaries were enrolled in MCOs as of July 1, 2022. Several states have recently implemented Medicaid managed care programs. Beginning July 1, 2021, North Carolina implemented its first MCO program, enrolling more than 1.8 million Medicaid beneficiaries in MCOs as of December 2022. Missouri implemented the ACA Medicaid expansion in October 2021, enrolling all expansion adults in Medicaid MCOs, and Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. State managed care contracts vary widely in the populations required to enroll, the services covered, and the quality and performance incentives and penalties employed. Five multi-state, for-profit “parent” firms – Centene, UnitedHealth Group, Anthem, Aetna/CVS, and Molina – each have Medicaid MCOs in 12 or more states and account for half of all Medicaid MCO enrollment. MCOs are expected to play a large role in helping enrollees maintain coverage during the unwinding of the continuous enrollment provision. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023.

In response to the pandemic, all states took action to expand coverage and access to telehealth in Medicaid, particularly for behavioral health services. In particular, nearly all states added or expanded audio-only telehealth coverage. These policy changes contributed to high telehealth utilization by Medicaid enrollees during the pandemic, overall and especially for behavioral health services. The rapid expansion of Medicaid telehealth policies and utilization has prompted state and federal questions about the quality of services delivered via telehealth. Most states have implemented or are planning initiatives to assess telehealth quality, though many states report ongoing considerations and uncertainty over how to effectively evaluate quality. States also report actions to address other telehealth challenges, including access to technology and broadband, program integrity, outreach and education, and equity. Most states have or plan to adopt permanent Medicaid telehealth expansions that will remain in place after the pandemic, including expansions of allowable modalities, services, and providers. At the same time, some states are considering guardrails on such policies, particularly for audio-only telehealth.

Beyond telehealth, many states are taking steps to expand access to behavioral health services as the pandemic has heightened demand for these services. Nine in ten Americans believe the nation is in the midst of a mental health crisis. Behavioral health conditions (i.e., mental health and substance use disorders) are more prevalent in Medicaid enrollees compared to people with other coverage, with data from 2020 showing that approximately 39{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of Medicaid enrollees were living with a mental health or substance use disorder. States have been expanding behavioral health benefits and access to care, including by adopting strategies to bolster the behavioral health workforce. These state efforts track with continued activity at the federal level: the Consolidated Appropriations Act and the 2022 Bipartisan Safer Communities Act included an array of provisions to expand access and funding for behavioral health, such as provisions to require guidance on expanding Medicaid-covered mental health services in schools, expand Certified Community Behavioral Health Clinics (CCBHC), fund new psychiatry residency positions, and eliminate administrative requirements to prescribe buprenorphine.

States and the Administration have identified advancing health equity as an important priority for the Medicaid program. The pandemic exacerbated longstanding racial and ethnic disparities in health and health care. Medicaid policies that could help address health equity include closing the “coverage gap” for adults in non-expansion states; increasing coverage among those eligible but not enrolled; and expanding benefits such as pregnancy and postpartum services, housing and housing-related supports, and community health worker services. High-quality, comprehensive data are essential for identifying and addressing health disparities and measuring progress over time and the majority of states are implementing strategies to improve race, ethnicity, and language (REL) data completeness. States are also using MCO financial quality incentives (e.g., performance bonuses, withholds) tied to health equity-related performance goals and other MCO contract requirements to advance health equity. Other reported state Medicaid initiatives to reduce racial health disparities include outreach to underserved populations, increasing cultural competency, and establishing departments and dedicated staff positions focused on promoting equity. In addition, states have received or are seeking Section 1115 waivers that aim to advance equity.

States and the Administration are implementing strategies to leverage Medicaid to address social determinants of health (SDOH) through managed care and Section 1115 waivers. The Biden Administration has encouraged states to propose waivers that expand coverage, reduce health disparities, and/or advance “whole-person care,” including by addressing health-related social needs (HRSN). Recent waivers approved in four states (AR, AZ, MA, and OR) include HRSN services to address food insecurity and/or housing instability for targeted populations. Additionally, following the approval of a California proposal to use “in lieu of” services (ILOS) to offer a menu of health-related services through managed care authority, the Centers for Medicare and Medicaid Services (CMS) recently released additional guidance on the use of in lieu of services and settings in Medicaid managed care to reduce health disparities and address unmet HRSN (such as housing instability and nutrition insecurity).

What to watch?

  • How effective will state and administration efforts to leverage Medicaid be in addressing SDOH and reducing health disparities? How will states use authorities including Section 1115 and managed care to pursue these goals?
  • What kinds of permanent telehealth expansions and/or guardrails will state Medicaid agencies adopt, and how will these policy changes be informed by data analyses, federal guidance, and cost concerns?
  • Will the Administration release new guidance in 2023 to address access to care and what provisions will be included in the anticipated access and revised managed care regulations?
  • Will Congress pass additional legislation and / or will states take additional actions to improve access to and funding for behavioral health services?

Enrollment and Access Among People Eligible for Medicaid through Age or Disability

The new proposed rule on eligibility and enrollment could increase enrollment among all Medicaid eligibility groups, but especially among seniors and people with disabilities. A proposed rule designed to make it easier for people to obtain and maintain coverage in Medicaid and CHIP includes provisions to simplify the enrollment and renewal processes for seniors and people with disabilities by applying many of the ACA’s simplified eligibility processes for children and other adult eligibility groups to these groups. There would also be simplified enrollment procedures for people who receive supplemental security income and people who are enrolled in Medicare but eligible for Medicaid coverage of Medicare premiums. KFF analysis finds that over one-third of Medicare-Medicaid enrollees lose Medicaid coverage within one year of their initial enrollment, which is one of the reasons for the proposed changes. CMS expects that the rule would increase Medicaid enrollment by nearly 3 million full-year equivalents, with seniors and people with disabilities accounting for over half of that total.

Staff and residents at long-term care facilities have been disproportionately affected by the pandemic. Over one-fifth of all deaths from COVID-19 were among residents and staff in long-term care facilities as of June 12, 2022. Although initial vaccination rates were high and the death rate among nursing facility residents and staff dropped, take-up of boosters and of the new bivalent booster has been much lower. Going into the 2022-2023 winter period, fewer than half of residents and one quarter of staff were up-to-date with their vaccinations, which may result in higher death rates moving forward. Compounding the challenges with COVID-19 illness is the ongoing workforce shortage for long-term care facilities. Whereas employment in most health care sectors has rebounded from the sharp drop in March 2020, employment in long-term care facilities remains well-below pre-pandemic levels.

The pandemic also highlighted workforce shortages and unmet need among people who use long-term services and supports (LTSS) delivered in home and community settings (HCBS). In a KFF survey of HCBS programs, nearly all states reported that workforce shortages were the number one impact of the COVID-19 pandemic on HCBS services and 44 states reported that at least one HCBS provider permanently closed. Virtually all states increased payment rates in response, but some of those increases are temporary rather than permanent. Many changes to HCBS programs relied on temporary funding through the ARPA or temporary authorities available during the PHE. Policymakers of both parties have called for additional and longer-term changes to HCBS including eliminating waiting lists for services, increasing opportunities for family members to be paid caregivers, enabling more people to live in their homes as they age, and permanently increasing wages for all HCBS providers.

There is bipartisan interest in improving the coordination for Medicare-Medicaid enrollees (also known as “dual eligibles”). People who are enrolled in both Medicare and Medicaid tend to have significant health and functional needs and higher health care spending than people with only Medicare or Medicaid. Policymakers have expressed interest in improving the coordination between Medicare and Medicaid with the goals of improved health outcomes and, possibly, reduced health care spending. Most recently, a bipartisan group of senators released a request for information, soliciting input from patients, providers, payors, and other stakeholders.

What to Watch:

  • How will the final eligibility and enrollment rule increase enrollment for seniors and people with disabilities?
  • Will nursing facility residents and staff be at increased risk of death as the virus evolves and immunity wanes among people who are vaccinated but not up to date? What efforts will emerge to improve rates of booster take-up?
  • How will the end of ARPA funding and PHE authorities affect access to HCBS?
  • Will bipartisan interest in improving the coordination between Medicare and Medicaid result in new legislation addressing Medicare-Medicare enrollees and their access to care?

When US hospitals go private, Medicaid patients lose health care access

Over the past four decades, US hospitals have gradually moved from public hands to private ones. The share of hospitals owned and operated by a government body — as opposed to a private entity, either a for-profit enterprise or a nonprofit — declined by 42 percent from 1983 to 2019.

That trend has brought serious consequences for the poorer patients who seek care at these hospitals. When private companies assume control of public hospitals, low-income patients on Medicaid lose access to health care, according to new research on this longstanding but under-analyzed trend in American health care.

A new National Bureau of Economic Research working paper by academics from Stanford, Michigan State, and Penn reviewed the consequences of the 258 hospital privatizations from 2000 to 2018 they could identify using national data. (As there were a little more than 1,000 public hospitals in 1999, that would mean one-fourth of all US public hospitals were privatized over the period they studied.)

These researchers found that after a private company took over a hospital previously controlled by the government, the hospital becomes more profitable. As a public hospital, these facilities lost about $335 on average for every patient. As a private hospital, they earned about $740 per patient.

In an ideal world, hospitals could be operating more efficiently, and therefore more profitably, without sacrificing access to health care. And the researchers do find that the hospitals achieve greater profitability in part by reducing spending on administrative and support personnel rather than people most directly involved in patient care. There was no meaningful reduction in nursing staff, for example, after the transfer of control.

But the other way in which these hospitals increased their profitability is more worrisome. Hospitals taken over by private companies saw an 8.4 percent decrease in overall patient volume, partly the result of hospitals reducing their capacity in a likely bid to improve efficiency.

Admissions for Medicare dropped by only 5 percent, a statistically insignificant change, according to the researchers. But Medicaid admissions fell by 15 percent, as did the decline in “other” admissions (which include the uninsured and private insurance, with the former representing another unprofitable business line for hospitals). Though Medicaid patients made up 20 percent of patient volume at these hospitals, they accounted for 30 percent of the drop in admissions after privatization.

“These patterns are consistent with private owners wanting to reduce the share of Medicaid and Other patients at their hospital in order to increase mean revenue per patient,” write the paper’s authors.

I asked the authors what hospitals turning away Medicaid patients might look like in practice. They could only speculate, as that was beyond the scope of the paper, but Mark Duggan at Stanford told me that perhaps the most straightforward way would be for them to decline to renew their Medicaid contracts, taking the hospital out of the provider network for Medicaid patients. Atul Gupta at Penn also said that they could cut certain lines of service, such as psychiatric care, that are more frequently used by Medicaid patients. Or they could decline to admit Medicaid patients; while they are obligated to stabilize a patient in the emergency room, they have more discretion about which patients to actually admit into the hospital.

In theory, fewer Medicaid patients could mean simply that there are fewer unnecessary hospitalizations. But the researchers tested that idea by examining what happened to patient volume across an entire area when a hospital was privatized. They found patients with Medicare or private insurance were absorbed by the neighboring hospitals — but Medicaid admissions dropped across the region.

In other words, when newly privatized hospitals decreased admissions, the patients with more lucrative health insurance were picked up by other facilities, which would suggest they still had clinical needs that the market then rose to meet. But Medicaid patients, whose insurance is not as generous, simply lost access to health care.

“The aggregate decline in Medicaid volume potentially hurts its effectiveness as a social insurance program that ensures access to medical care for vulnerable low-income beneficiaries,” the researchers write. “Privatization therefore emerges as a channel that may curb utilization of care by Medicaid beneficiaries.”

The consequences of hospital privatization for Medicaid patients have gained more importance given the recent expansions of Medicaid eligibility. Medicaid has now grown to become the single largest health insurer in the United States, covering more than 90 million Americans (including the related CHIP program that covers kids). But, as the authors noted in their analysis, that rise in enrollment has not been matched by a commensurate increase in hospital admissions by Medicaid patients. Their findings may help to explain why.

Medicaid is vital to the US safety net, providing zero-cost insurance coverage for low-income Americans. It also has its problems, with low reimbursement rates leading fewer doctors to accept Medicaid patients. One of the most interesting research papers from last year found that supposedly “adequate” physician networks for people enrolled in Medicaid managed care plans (which are overseen by private companies) were not as robust as they first appeared to be.

Giving people Medicaid coverage is the first step to making sure vulnerable Americans get the health care they need — but it is only the first step. They need to find doctors and hospitals that will accept their insurance and treat them. That has been a longstanding struggle because of the program’s low reimbursement rates, which are substantially less than Medicare or private insurance.

And, according to this new research, the trend toward hospital privatization is making the problem worse.

Yes, I’ll give $120/year

Yes, I’ll give $120/year

Millions of Americans to lose Medicaid coverage starting next year

Hundreds of thousands of Us residents received Medicaid coverage throughout the pandemic. Starting subsequent year, tens of millions are probably to drop it.

The mammoth expending invoice handed by Congress would enable states to kick some people off Medicaid commencing in April. Millions would come to be uninsured, according to estimates from the administration and a number of wellbeing treatment nonprofits.

The Kaiser Household Basis estimates that 15 million to 18 million persons will eliminate Medicaid coverage — or about 1 in 5 persons currently in the system. A December analyze by the centrist City Institute also believed that 18 million folks are established to reduce Medicaid coverage up coming year and in 2024, leaving 3.8 million folks devoid of well being insurance plan. 

“The actuality is that hundreds of thousands of men and women are going to drop Medicaid protection,” explained Jennifer Tolbert, the foundation’s associate director of the system on Medicaid and the uninsured.

Public well being crisis

Because the coronavirus first struck in 2020, enrollment in Medicaid — the health insurance coverage application for very low-revenue people — has swelled by 20 million, to practically 84 million people today, in accordance to KFF. That is by design: When the administration initial declared the public wellbeing crisis (PHE), it also barred states from kicking folks off Medicaid.

In a typical year, numerous individuals enroll in Medicaid and numerous some others depart as their money or instances modify. States operate program checks on Medicaid users to make confident they are nevertheless qualified for the method, and throw out anybody who isn’t really. The general public well being unexpected emergency halted that procedure.

“There are a lot of reasons individuals move on and off Medicaid, but what the PHE has completed is, for the final handful of years, no one particular has moved off Medicaid,” Tolbert claimed.


New exploration states 100 million in U.S. saddled with credit card debt from wellbeing treatment

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The shelling out bill would make it possible for states to start off kicking people today off commencing April 1. The federal governing administration will also wind down excess resources offered to states for the added enrolees over the up coming calendar year beneath the proposal.

“Unwinding the pandemic Medicaid steady coverage provision is probable to be particularly difficult, and states have major function to do to defend people from losing wellbeing coverage,” Allison Orris, senior fellow at the liberal-leaning Center on Finances and Plan Priorities, stated in a recent blog write-up.

In advance of states remove Medicaid customers, they are needed to check patients’ eligibility and notify men and women if they’re shedding protection.

“What the condition is needed to do is use obtainable digital details sources to evaluate regardless of whether the human being is however suitable for Medicaid. They will examine items lke residency, do they however reside in the point out, what their recent earnings and spouse and children scenario is, and. based mostly on that, do they still meet up with the eligibility needs,” Tolbert stated. 

Nonetheless, she added, it is really not unusual for persons who are suitable for Medicaid to even so get dropped from the plan since of language limitations or administrative oversight. “Probably at their yearly renewal they missed a notice to offer documentation, or they did not know how to deliver documentation,” she mentioned.

Advocates have also lifted problems about how states will notify enrolees if they are remaining kicked off the program and what their selections are. The hard work will be notably challenging for some of the country’s poorest people today, who may perhaps not have a steady dwelling address or accessibility to web or phone providers to check their status.


Expanding postpartum Medicaid protection in Michigan

04:40

When will men and women get rid of coverage? 

The omnibus spending bill enables states to fall folks from Medicaid starting off April 1, but a lot of will probable just take for a longer period. The Facilities for Medicare and Medicaid has suggested that states acquire a complete year to re-examine everybody in the method — despite the fact that states are not essential to follow that direction. 

“Transferring these people off Medicaid isn’t really heading to occur on day a person,” stated Chris Meekins, an analyst with Raymond James who follows overall health care. “I be expecting red states have taken measures previously to identify who they believe that most very likely to be ineligible, to focus on those people people initially,” he mentioned.

A lot of men and women who get rid of Medicaid will be able to find other health insurance policies, these types of as through an employer, the Reasonably priced Treatment Act market or, in the case of children, the Children’s Health and fitness Coverage Software. But about 5 million will keep on being uninsured — a potentially devastating problem.  

“These men and women you should not truly have wherever else to go to get coverage,” Tolbert stated. “Simply because they continue to be qualified for Medicaid… they can not go to the market and get protection.”

Even if people men and women at some point re-enroll in the method, industry experts worry that going without having well being insurance policy for months could be disruptive for any person with ongoing wellness treatment challenges. 

“Probably you go to your doctor’s business and locate out you do not have protection, and you can’t get solutions that working day for the reason that you need to have to reapply” for Medicaid, Tolbert reported. 

Wellness care advocates urge folks who are on Medicaid to make guaranteed their contact facts is up to day on their accounts and that they verify the mail frequently to keep an eye on their eligibility status as that April 1 date nears.

The paying monthly bill also frees up further funds to pay out for much more stable well being insurance policies protection for small children in small-profits homes, by demanding states to keep individuals children on Medicaid for at minimum a calendar year after they’ve enrolled.

The Related Press contributed reporting.

Abortion, Medicaid highlight state health ballot tests

Illustration of a caduceus over a divided red and blue background with elements of ballots.

Illustration: Brendan Lynch/Axios

Whilst inflation and the economic system have been foremost on voters’ minds across the nation this election cycle, some of the most large-profile health and fitness treatment battles are being made a decision at the point out degree on Tuesday.

Driving the information: Voters in Michigan, Kentucky, Vermont, California and Montana are weighing abortion ballot thoughts that push residence how crucial reproductive rights battles publish-Roe are becoming waged exterior the federal realm.

  • Somewhere else, there are steps dealing with Medicaid expansion, the regulation of the dialysis sector, and even irrespective of whether entry to well being care is a lawfully enforceable ideal.

The huge image: The most important outcome for wellbeing treatment continues to be whether or not Republicans retake a single or both equally homes of Congress.

Here is what we are seeing:

Problem: Abortion legal rights.

Zoom in: Voters in California, Michigan and Vermont will consider no matter whether to amend their condition constitutions to safeguard the right to abortions.

What to know: This kind of initiatives strengthen turnout, as we saw in the Kansas primaries when an amendment that would have struck abortion protections in the state’s constitution was soundly rejected.

What to enjoy: “The community is not as extraordinary as the politicians on both equally sides of the political spectrum. They’re likely to not want a digital ban on abortions, specially when the wellness of the mother is at stake, when there is rape or incest, or a really unacceptably quick time interval,” Lawrence Gostin, a legislation professor at Georgetown College, explained to Axios.

  • “I assume you may possibly see, like in Kansas, individuals moving to moderation equally on health and fitness treatment and abortion,” Gostin said.

Go deeper: Struggle for abortion rights moves to state ballots

Difficulty: Medicaid expansion

Zoom in: South Dakota, one particular of a dozen Republican-led holdout states that have not expanded their Medicaid packages, will set the problem to voters, for each Lucille Sherman and Emma Damage.

  • Voters there in June turned down a GOP proposal that would have lifted the threshold for passage.
  • “It just would make perception. It is time to get over it,” Greg Jamison, a Republican South Dakota condition representative informed the New York Times about his personal aid for enlargement.
  • If Measure 28 succeeds, it would grow Medicaid eligibility to about 42,000 folks at a whole cost of $1.5 billion for the initial 5 several years, with the state’s share getting about $166 million in that time.

Be wise: The idea is catching on in much more purple states. Ballot issues on the problem passed in Nebraska, Utah and Idaho in 2018 and Missouri and Oklahoma in 2020.

Situation: Overall health treatment as a appropriate

Zoom in: Voters in Oregon will vote on irrespective of whether or not to make the condition the to start with to enshrine a suitable to health treatment with Measure 111, the Involved Press reviews.

  • If handed, the state would have an obligation to make certain people have entry to “price-successful, clinically suitable and affordable health and fitness care.” This would not need universal or single-payer well being protection.
  • Supporters say it would drive the legislature to prioritize bringing down the cost of health treatment, and could direct the condition to make moves like increasing Medicaid or point out subsidies for health designs in buy to close the coverage gap.
  • Opponents say the evaluate will guide to far much more individuals getting on Medicaid and direct individuals to sue the condition above their well being care, Oregon Public Broadcasting described.

What they are declaring: “You could uncover a good deal of litigation in the state’s courts these as ‘I have the suitable to this extremely expensive medicine,'” Gostin claimed. “The constitutional provision would be for ‘cost-successful well being care’ so that offers the state some hedge in the courts. But I consider they will have to protect them selves in litigation.”

  • Yes, but: The state may run into difficulty with mental well being or material use remedies, areas that usually have lengthy waits to entry treatment and generally will not have terrific insurance coverage coverage, he explained. “That opens the point out up to litigation that could perfectly do well,” Gostin reported. “It could be pricey for the condition.”
Problem: Dialysis rules

Zoom in: Voters in California will contemplate whether or not to approve tighter restrictions for the dialysis industry, these as a requirement to have an on-site health practitioner all through all hrs of procedure.

  • Clinics would also have to report dialysis-linked infections and disclose the names of everyone who personal at minimum 5{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the clinic.
  • This evaluate is back after owning been defeated 2 times in the previous 5 a long time and can take aim at vastly rewarding dialysis giants like DaVita and Fresenius Medical Care.

In between the strains: This is one of the most pricey ballot initiatives in record, coming up for the third election cycle in a row.

  • The union backing the proposal has used $8 million this time all around, declaring it’s important to safeguard sufferers.
  • Meanwhile, the field has poured $86 million into rallying the opposition of people, for every the Los Angeles Times. In all, the dialysis marketplace used additional than $233 million, together with in lobbying, to struggle the condition restrictions by 2020.
  • They have warned the proposition would pressure clinics to demand far more or “shut down dialysis clinics during California.”
Issue: Flavored tobacco products ban

Zoom in: An additional health-relevant measure on the ballot in California would let voters to reaffirm or overturn a ban on flavors in certain tobacco products this kind of as menthol cigarettes or candy-flavored vaping juice.

  • The ban was passed two several years ago, but the tobacco business lobbied ample aid to set the concern to a vote, ABC News stories.

State of perform: Although physicians, children’s well being advocates and the state’s Democratic celebration assist retaining the ban, the state’s Republican celebration has pushed versus the law for the reason that it cuts into a major supply of tax profits, for each ABC.

  • Other opponents have pushed for greater taxes, instead than an outright ban on these merchandise.
Difficulty: Professional medical financial debt procedures

Zoom in: An Arizona evaluate, Proposition 209, would decrease the highest total of desire lenders can cost on health care personal debt to 3{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, from a prior cap of 10{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}.

  • It would also improve the assets exempt from debt assortment and let courts to lessen how substantially of a person’s earnings can be garnished.

Concerning the strains: The evaluate could develop into a design in states unwilling to deal with medical credit card debt via their legislatures.

Certainly, but: Critics have warned efforts concentrating on professional medical financial debt can have unintended and highly-priced penalties on all client personal debt and selection therapies.