Avoiding the Great ‘Unwinding’ – 15 Million People at Risk of Losing Medicaid
On April 1, 2023, states will resume reviewing all 86.7 million Medicaid enrollees’ eligibility for the first time since the pandemic started and will begin ending coverage for those found ineligible. This process is called “unwinding” and, according to estimates, it could result in up to 15 million people leaving the program.
Eligible individuals and families — particularly people of color and children — are at risk of losing coverage during the unwinding process despite remaining eligible for Medicaid or becoming eligible for other types of low-cost coverage, due to administrative hurdles they must overcome to maintain their coverage.
EMS teamed up with experts – Farah Erzouki, Senior Policy Analyst, Center on Budget and Policy Priorities (CBPP); Laura Guerra-Cardus, Director of State Medicaid Strategy; and Kristen Testa, Director, California Health Programs, Children Partnership – to bring this topic to the attention of ethnic America and to explain how to avoid losing badly needed coverage.
Farah Erzouki, senior policy analyst for the Center of Budget and Policy Priorities gave a first look of what is ‘unwinding.’
“A pandemic era law prevented states from ending people’s Medicaid coverage during the public health crisis, but that provision is ending on March 31, and states can soon begin resuming their regular renewal process and terminate coverage for Medicaid enrollees beginning April 1. This is the process termed ‘unwinding,’” said Erzouki.
“Medicaid unwinding will be the largest healthcare event since the implementation of the Affordable Care Act and experts estimate that over 18 million people could lose their Medicaid coverage, despite millions still being eligible.
“The risk of coverage loss is particularly high for communities of color and children.
“Since March of 2020, through COVID legislation, states have mostly kept people covered through Medicaid without interruption in exchange for an increase in their Medicaid Federal matching funds. This policy known as the continuous coverage requirement allowed millions of people to keep their Medicaid during the public health crisis and not be subjected to paperwork requirements or other administrative barriers that usually result in people turning on and off the program. Enrollment in Medicaid has grown by over 30 percent to nearly 84 million people since February 2020.
“Access to coverage and health care services has been critical during this time of increased hardship.
“At the same time, this continuous coverage policy has meant that most Medicaid enrollees probably have not had contact with their Medicaid agencies in three years and in some cases, even longer.
“People may have moved during the pandemic, meaning their addresses and contact information have potentially changed. This poses a risk during the unwinding process that people may not receive their renewal notice or some important information in the mail, and if they do, they may not understand it or might struggle to submit the information on time.
“These challenges will be made even more difficult with the staffing crisis that Medicaid agencies are facing, all while preparing to manage the historically high caseloads ahead of them.
“Medicaid agencies could fall behind in processing cases and documents and all of these challenges combined, could result in large coverage losses.
“Experts estimate that 18 million people will lose their Medicaid coverage during the unwinding process, with 7 million of them still being eligible but losing coverage for procedural reasons. “We know that procedural barriers or the red tape that people experience in trying to access Medicaid have deep roots in systemic racism.
“People of color are disproportionately impacted by these procedural barriers and this makes it more difficult for them to enroll and stay enrolled in safety net programs like Medicaid despite being eligible.
“Research predicts that while 17% of White enrollees will lose coverage during the unwinding for procedural reasons. Latino, Asian, native Hawaiian Pacific Islander, and Black enrollees are much more likely to lose coverage for those reasons 64.50% and almost 40%, respectively. “Additionally, almost three in four children are predicted to lose coverage despite being eligible.
“These stark numbers underscore the inequities that communities of color and children experience and the need for an all hands on deck effort to support these impacted populations through the unwinding process,” said Erzouki.
“It takes dates anywhere from 60 to 90 days to complete a full renewal. Some states will initiate renewals as soon as February, meaning that some enrollees will start receiving notices in the mail about their coverage soon, but other states won’t begin initiating their renewal process until April, so we will see drops in coverage in those states starting to happen closer to over the summer.
“Most states will take 12 months to process their full caseloads. This will be a long process that will happen through the rest of 2023 and well into 2024.
“One of the most important things for state agencies to do is to make sure they are communicating effectively with Medicaid enrollees. To do this, agencies should work to make sure they have updated enrollee contact information so that when notices start to come in the mail, people receive them, and know, it’s time to act. They should also use different methods to contact people like text message and email, especially given it may be more difficult than usual to reach them by mail,” said Erzouki.
“We know that Medicaid agencies are facing a staffing crisis and there are strategies that states can employ that would simplify the renewal process and reduce the strain on workforce.
“State agencies should automate more renewals using electronic data, so they don’t have to contact every single enrollee directly to renew their coverage. This would reduce procedural errors and would also ease the strain on caseworkers.
“They should also make sure that people can renew their coverage online or over the phone. This is a federal requirement, but some states have yet to implement it and they should find ways to address their staffing shortages by hiring more workers; allowing overtime; or bringing back retirees.
“These fixes are worth investing energy into, even if they aren’t ready. When the unwinding process begins, the stakes are high with the coverage of millions of people on the line and proven solutions at their disposal, state agencies must act to make this process smooth and effective to protect enrollees and minimize coverage losses,” said Erzouki.
“There is a lot that states can do, and need to do, to prepare for the unwinding, so that eligible people do not lose coverage, and states across the country will do a variety of quality of job,” said Laura Guerra-Cardus, director of State Medicaid Strategy.
“Their work in this area will vary state to state. It is critical that in addition to urging state leaders and state agencies to do all they can, that we also do all we can to make sure that communities of color have the information they need to protect their coverage and their families’ coverage.
“Ethnic media outlets can serve as a central partner in helping protect people’s coverage and the care and financial protections that come with it,” said Laura.
“People need to make sure to check their mail and keep an eye out for letters from either Medicaid or CHIP. They could receive their renewal notices at some point this year or early next year because states will have about a year to initiate the renewals. People could be on the earlier side of the renewal process, or on the later side.
“People should complete the renewal forms if they get one. For those that no longer qualify for Medicaid, they may be able to get affordable coverage through the Affordable Care Act marketplace, learn more by visiting healthcare.gov.
“The majority of those going through the redetermination will have an affordable coverage option available to them no matter their new income or circumstance.
“However, in the 11 non-expansion states that remain, hundreds of thousands of people stand to lose their Medicaid coverage with no other affordable coverage option available to them.
“Those most likely to fall into the Medicaid coverage gap where they don’t qualify for their state’s Medicaid program but do not earn enough money to get financial assistance on the marketplace are the following groups – young adults who turn 19 during the pandemic and will no longer qualify for children’s coverage; parents with extremely low incomes who either no longer have a dependent child or their income has risen above the very low threshold that the states has; and the third is postpartum people that are past their state’s eligibility period which could be anywhere from 60 days to 12 months after the end of pregnancy in the non-expansion states.
“For these groups, to avoid falling in the Medicaid coverage gap, often their income needs to rise significantly. For example, a Texas mom would have to see her income rise six times from $3,700 to $23,000, to be able to get an affordable coverage option in the marketplace,” said Laura.
“The Medicaid coverage gap disproportionately impacts people of color. People of color make up 60 percent of people in the gap reflecting systemic racism embedded in our nation’s education, economic, and other systems, that have made communities of color disproportionately likely to have lower incomes.
“With the potential for massive coverage loss ahead of us, now is the time for state policy makers to ensure their states use every mean available to avoid massive coverage loss when the unwinding begins.
“This includes doing what they can to streamline the renewal process and ensure the eligible people remain enrolled and it also means expanding Medicaid to ensure that people of their state can access Affordable Health Care coverage no matter their income,” said Laura.
Kristen Testa, director of California Health Programs at Children Partnership, spoke about how ‘unwinding’ would affect children, and what’s going to happen in states like California, that are expansion states.
“Communities across the country are going to be affected, even if you personally are not covered by Medi-Cal,” said Testa.
“In California, the numbers are clear, we have 15 million people covered by Medi-Cal in California, that’s one-third of all Californians, that use this as insurance for children. Over half of all California children have coverage through Medi-Cal.
“This unwinding will have a tremendous effect on all those families. So many of them are still going to be eligible. The only reason they’re losing is because they got tripped up in the paperwork; they may have moved and had changed address, and never got their renewal forms; they were unclear and confused because in California they kept getting these notices throughout the public health emergency, but now they need to respond to them.
“The important thing is for everybody to know and help our community renew their coverage and know where to go.
“There are County offices that renew applications for Medi-Cal, but there are also community organizations and health plans that can help families with their renewal.
“These are going to be very important to connect families, to make sure they can renew their coverage.
“California is trying to do its best to get the word out, but there will be clogged lines, calling in and trying to get your change of address, included.
“We need to have a whole all-hands-on-deck approach now. Continuous coverage is something that we value very much, and in California, this past budget year, we passed a law that would continue continuous coverage for young children because at this time in their lives, when 90% of brain development is happening, we want to make sure they have no gaps in coverage,” said Testa.
“Unfortunately, the continuous coverage policy in California won’t begin until 2025, not in time for this unwinding. Some children will lose coverage and we are pushing our state to implement that permanent policy for young children as soon as possible,” said Testa.
