Out of the 83 million Americans enrolled in Medicaid, nearly half of whom are children, around 23 million have lost or are at risk of losing coverage since the pandemic. The federal COVID-19 emergency temporarily halted the annual Medicaid eligibility checks, known as redetermination. 

With the lifting of the emergency in May 2023, the redetermination process has resumed, affecting nearly one in four Americans and almost half of all children on Medicaid. This resumption has exacerbated existing coverage gaps in many states.

In a media briefing on August 9, hosted by Ethnic Media Services, a panel discussed these coverage gaps in Medicaid.

Speakers

  • Katherine Hempstead, Senior Policy Adviser at the Robert Wood Johnson Foundation
  • Stan Dorn, Director of the Health Policy Project at UnidosUS
  • Martha Sanchez, Health Policy and Advocacy Director at Young Invincibles 
  • Joan Alker, Executive Director and Co-Founder of the Center for Children and Families and Research Professor at Georgetown University

Redetermination and Coverage Gaps

“Because of the bureaucratic hoops that people need to jump through, the past year has been like a disenrollment churn on steroids, even for many who are still eligible,” said Katherine Hampstead.

A staggering 69% of these disenrollments are due to paperwork issues rather than actual ineligibility. As of April 2024, nearly a quarter of the 20 million people dropped from Medicaid since redetermination began remain uninsured.

“Medicaid is the largest single source of health insurance in the country, but there’s both federal and state money going into it … so it’s like 50 different programs state to state,” Hampstead explained. She further noted that redetermination is particularly widening coverage gaps for populations that Medicaid was originally designed to serve, such as low-income groups, seniors, people with disabilities, children, and pregnant women.

These coverage gaps are disproportionately impacting communities of color, especially in the 10 states, mostly in the South, that have not expanded Medicaid income limits from 100% to 138% of the Federal Poverty Level (FPL) for adults aged 19 to 64.

This expansion of the FPL was permitted by the Affordable Care Act and was ruled optional for each state by the Supreme Court in 2012.

As of 2024, the FPL stands at $14,580 for an individual, with 138% of that being $20,783, and $24,860 for a family of three, with 138% of that being $35,632.

In states that haven’t expanded FPL limits — including Florida, Texas, Georgia, Alabama, and Mississippi — “there’s a coverage gap where two to three million people, predominantly populations of color, are in a very unfortunate situation where they’re ‘too poor’ to get marketplace subsidized coverage, yet they don’t qualify for Medicaid because their state’s eligibility limit is so low,” said Hampstead.

The Younger Generation

“Despite our name, young people are not invincible,” said Martha Sanchez. “We’re the future of our U.S. workforce and economy, and we cannot afford to continue to regress in our health.”

Approximately 30% of young adults in the U.S. aged 18 to 34 are uninsured, a rate higher than any other age group, comprising over one in five of all uninsured Americans.

A 2019 CDC study revealed that at least half of young adults have at least one chronic condition, such as diabetes, cancer, or mental health issues. Since the pandemic, these conditions have been on the rise, with one-third of all young adults — and half of those aged 18 to 24 — reporting symptoms of mental illness.

The American Cancer Society has also reported increasing rates of cancer among young adults, particularly types typically associated with older adults, like colon cancer.

“We’re in a crisis where our health care systems are not meeting the needs of our young people, who are often in a stage of transition out of Medicaid … because there’s no expansion, they’re sold student health plans or they don’t know how to enroll in other plans,” Sanchez explained.

“I grew up on Medicaid, and I never understood all of the benefits I had until I transitioned out as a college student,” she added. “I had annual checkups, vaccinations and dental care, but I had no idea about the mental health benefits. And we’ve heard this from other young adults who shared that they would have taken advantage of mental health resources, but had no idea it was covered … We need not only Medicaid expansion but health literacy, so people can actually use their coverage.”

Since redetermination, 5.5 million fewer children under 18 are enrolled in Medicaid as of July 2024.

“Many of these children remain eligible, and we need to get them back enrolled, particularly in back to school right now,” said Joan Alker.

The changes in Medicaid enrollment vary significantly between states. Texas has seen the largest drop by number, with 1.3 million fewer children enrolled, followed by Florida with approximately 542,600 fewer children, and California with 373,000 fewer children. The largest percentage drops are in Utah, with 34.5% fewer children on Medicaid, Colorado with 30.9% fewer, and Texas with 29.1% fewer children enrolled.

“We’ve heard that parents are putting off care because they’re not insured, and just hoping their child doesn’t get sick. That children are having to skip their medications, not getting their inhalers, and missing treatments for behavioral health conditions,” said Alker.

“Children are not expensive to our health care system, but they need regular care, so even a short gap exposes the family to large medical bills … and without that routine care, children are less able to learn,” she added. “Many of these children are still eligible for Medicaid. Any gap in coverage is not acceptable.”

What’s To Come?

“The price America pays for giving states enormous authority over their Medicaid programs is extremely high,” said Stan Dorn. “A family has a very different likelihood of getting health care based simply on the state in which they happen to live.”

To address these significant coverage gaps, Dorn proposed making “administrative burdens completely irrelevant for as many people as possible” by implementing paperless eligibility processes, providing linguistically and culturally accessible enrollment assistance, automatically renewing qualified individuals using existing tax and wage information, and ensuring continuous coverage even in cases of missing paperwork.

Given that states pay a portion of the cost for each Medicaid enrollee, Dorn also suggested establishing federal standards for state redetermination performance to incentivize states that are reluctant to pay.

States that exceed these standards could receive a bonus, similar to the approach used with the Children’s Health Insurance Program in 2009. For states that fail to meet the standards, Dorn suggested deferring federal payments until improvements are made, while ensuring that families are not terminated from coverage in the meantime.

“We found that the states with the worst problems in terms of people losing coverage had invested the least amount of money in their eligibility infrastructure. So ultimately, it’s a question of values,” said Dorn. “Are the states’ officials willing to invest enough money in running a Medicaid program that they would trust with their own family’s health care? Some are willing to invest in systems that work for families and providers, and others are not.”

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