Written by: Sahithi Gangavarapu

Millions of Americans nationwide have lost Medicaid coverage since March 31, 2023, when a pandemic-era mandate for coverage expired. As of November 21, 2023, 10.8 million Americans have been disenrolled from Medicaid, including around 2.1 million children. Recent data shows that a large proportion of these people are being disenrolled for administrative and procedural reasons unrelated to their actual eligibility leaving many people in need without healthcare coverage. As coverage losses continue to increase, millions of children and families are being detrimentally impacted.

What is Medicaid?

Medicaid is a joint federal and state program that pays for medical expenses for people with limited income and resources. It includes eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.

What was the pandemic provision?

At the start of the COVID-19 pandemic in April 2020, Congress enacted the Families First Coronavirus Response Act (FFCRA) which included a requirement that Medicaid programs keep people continuously enrolled through the end of the COVID-19 public health emergency in exchange for enhanced federal funding given to states. This was meant to help people during the pandemic by providing “continuous coverage” so that people would not lose coverage unless they moved out of state, requested cancellation, or passed away. “Continuous coverage” refers to the act of letting people keep their Medicaid coverage for a set period of time. This was not a new concept when it was implemented during the COVID-19 pandemic. Since 1997, states have had the option to provide 12 months of continuous coverage to children enrolled in Medicaid, giving them a full year of coverage regardless of changes in their family’s income. Continuous coverage was especially important during the pandemic for public health reasons, ensuring that uninsured individuals did not experience delays in accessing COVID-19 testing and treatment.

Why are disenrollments happening?

Other than people losing enrollment due to eligibility issues, recent data tracking disenrollments from the Kaiser Family Foundation show that 74 percent of people are losing coverage due to procedural disenrollment. Individuals are disenrolled for procedural reasons when there is no definitive determination of ineligibility, often due to issues such as paperwork not being returned or not received at all. Procedural disenrollments are worrisome because they can result in people losing coverage even if they are still eligible simply due to clerical issues. Filling out these forms can be confusing, and low-income communities are likely to be particularly affected, especially when they may lack the time or information to navigate through this process. These issues with coverage can result in missed medications, issues with accessing essential treatment, and a lack of trust in Medicaid and other benefit programs.

One recent case involved a Kentucky resident with severe anemia who needed surgery to treat chronic uterine bleeding. However, just days before her surgery, the hospital notified her that she did not have Medicaid coverage, putting her surgery in jeopardy. Initially, she had qualified for Medicaid through Supplemental Security Income (SSI), a program designed for individuals with minimal income or assets who are blind, disabled, or at least 65 years old. However, she was no longer eligible for SSI due to assets exceeding the federal limit in cash value. Although her income was still low enough to qualify for Medicaid, she lost coverage because her initial enrollment was dependent on SSI. Instead of retaining her coverage, she was required to complete renewal forms, but she never received them and was subsequently disenrolled. These instances, and many others, highlight the flaws in the current system, and the critical need to minimize procedural disenrollments.

How can we lower procedural disenrollment rates?

Under the Affordable Care Act (ACA), states are mandated to use electronic data matches with reliable sources to re-evaluate eligibility during renewal before necessitating enrollees to take action by filling out a renewal form or providing documentation. This process is called ex parte and is geared towards lowering procedural disenrollments. However, ex parte renewal rates are disappointingly low and the regulation is not always followed. Many state systems are not properly programmed to process ex parte renewals without worker action. Cases from Pennsylvania revealed that people enrolled in SNAP (formerly known as food stamps) were automatically excluded from the ex parte process. These logistical issues have been contributing to low ex parte rates and need to be addressed to prevent disenrollments moving forward.

Projected Impacts

Issues with the renewal process not only cause complications but also exacerbate inequities. According to projections from the U.S. Department of Health and Human Services (HHS), there is a higher likelihood of disenrollment for Medicaid enrollees from Latino, Black, Asian American and Pacific Islander, and multi-racial communities, even when they remain eligible for Medicaid. Furthermore, children are experiencing a disproportionate impact due to these coverage changes. These trends are only anticipated to worsen over time and it is imperative that the disparities in the renewal process are addressed to ensure equitable healthcare access.

Edited by: Johanna Bunn