More than 1.5 million Americans have lost their Medicaid benefits since April, as states begin the massive yearlong process of checking every beneficiary's eligibility. Millions more are expected to lose coverage in the coming months.
The "great unwinding," as it's known, is happening because the special protections established during the Covid-19 pandemic that prevented people from being removed from the program are officially off the books.
At this point, the available data would suggest that most people are losing Medicaid not necessarily because they are no longer eligible but because of administrative problems. The state couldn't reach them, they didn't return their paperwork, and so on. Nationwide, more than 70 percent of people who were removed from Medicaid lost benefits for a procedural reason.
That has left experts and advocates wondering: What is going wrong? And can anything more be done to stop people from losing coverage when they shouldn't?
The first question is difficult to answer. Attrition was always expected; even the low end of estimated losses envisioned upward of 8 million Americans losing their Medicaid. Some people really aren't eligible anymore, because they're now making more money or they've had a change in life circumstances that renders them ineligible. Even for people who are still eligible, they may be difficult to reach: They may have moved, or they may be elderly or have a disability, or they may simply ignore notices from the state government.
That was all baked in before the redetermination process began. Even so, the data reveals striking disparities across different states. In Idaho, for example, 73 percent of the people whose eligibility has been reevaluated have lost coverage; in Virginia, that share is much lower, at 16 percent, according to the health policy think tank KFF. In Kansas, 89 percent of all disenrollments have been for procedural reasons; in Iowa, only 28 percent have been.
But experts caution that data is not as easy to parse as it might seem; it's not as simple as that Idaho is taking a cavalier approach and Virginia is being more meticulous. Idaho actually paused disenrollments in April due to technical problems with their website, a sign that the state is taking care with the process. (Idaho is generally regarded as a well-administered Medicaid program.)
"The data we have now raises as many questions as it answers," said Jen Tolbert, who studies Medicaid at KFF.
It is at least in part a reflection of how states are tackling redeterminations. Some states, such as Idaho, have kept a list of people they believe are likely to be ineligible and have started the process by targeting them; it would make sense then that they would see a high rate of disenrollments early on, and those figures could come down as the year goes on. Virginia, on the other hand, is simply conducting redeterminations chronologically, which may explain its lower rate of disenrollments so far.
In addition, people who lose coverage have 90 days to seek a "reconsideration" and have their coverage restored retroactively. So if some of the people who lost coverage end up at the doctor's office or hospital, they may learn they've lost Medicaid and have an opportunity to re-enroll, which could ameliorate some of these coverage losses over time.
There is one final wrinkle experts must account for when analyzing this data. Some Medicaid beneficiaries may already know they are no longer eligible because, for example, they got a new job that offers health insurance. So they may ignore a notice from the government about losing their Medicaid coverage. That would be marked as a procedural disenrollment, but, in reality, the person was genuinely no longer eligible.
For all these reasons, we should be cautious about drawing firm conclusions about the redetermination data so far. A lot of people are losing coverage and experts are concerned about the number who appear to be dropping off Medicaid for procedural reasons. But it will take time for a clear narrative to become clear.
At the same time, however, experts do believe states could be doing more to make sure people don't fall through the cracks. For one, Idaho is an example of a state slowing down its redeterminations once evidence appeared of a lot of people losing coverage because of an administrative problem.
Experts flagged a few other strategies they believe are proving helpful for states trying to minimize the amount of unnecessary coverage losses:
- In Iowa, Tolbert said, the state is allowing case workers to override an automatic disenrollment if a person has not responded within the required time frame. That "seems to be working," she said, given the state's low rate of procedural disenrollments.
- New Jersey has been using the health insurance companies that administer its Medicaid benefits to communicate with beneficiaries, according to Kate McEvoy at the National Association of Medicaid Directors. Case workers who have an established relationship are helping to guide patients through the process. "That's not a formal letter," she said. "That's a trusted person with whom the Medicaid member has been working over time."
- Community is still the key: Medicaid officials in Kentucky and Nebraska have gone on a road tour, partnering with health clinics and hospitals, to get the word out. In New Mexico, formal letters from the state have been printed on distinctive turquoise paper to make sure people know what it is.
On the flip side, a more lax approach could result in states seeing higher coverage losses than are necessary. For example, Florida, which has already seen 300,000 people drop off the Medicaid rolls, did not take advantage of numerous policy options made available by the federal government (such as using data from SNAP to confirm a person's eligibility) that were supposed to make the redetermination process easier.
Sara Rosenbaum at George Washington University, who has studied Medicaid for years, said she would be watching Arkansas especially closely. Some states, such as Texas and Florida, may see large coverage losses in part because they do not have Medicaid expansion. There is no safety net for people to fall into.
But Arkansas has expanded Medicaid and actually integrated their Medicaid expansion plans into their Obamacare insurance marketplace. It should in theory be easy for the state to transition people from Medicaid to private coverage, given that setup. So far, the state has seen a high rate of disenrollments: 52 percent, the vast majority for procedural reasons, for a total of 110,000 people losing Medicaid so far.
The question will be: How many of those people end up getting covered by private marketplace coverage? Or, as Rosenbaum fears, did the state rush disenrollments with no solid plan for connecting those people to a new form of coverage?
"Did they rush the procedure so people were pushed off unnecessarily with the expectation that if they needed the coverage, they'd find their way back?" Rosenbaum said.
That is one of the many questions still to be answered as the Great Medicaid Unwinding continues over the rest of the year. We still have a long way to go and a lot to learn.
