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3 Essential Questions: The End of Medicaid Continuous Enrollment

March 16, 2023

As many as 14 million people in the United States could lose access to Medicaid health care coverage when the federal government’s Medicaid continuous coverage requirement unwinds over the next year. The provision, authorized by Congress in 2020 as part of the Families First Coronavirus Response Act, prohibited states from taking people off Medicaid during the pandemic health crisis, even if they were no longer eligible.

The continuous enrollment requirement is now scheduled to end on March 31, 2023, when the federal government begins scaling back its enhanced Medicaid funding to states that supported the expanded coverage over the past three years. As the provision unwinds, states will be allowed to resume checking individual eligibility and removing those who don’t qualify. The process is expected to be the single largest health coverage transition event since the Affordable Care Act took effect in 2013.

Dr. Chima D. Ndumele, MPH, PhD, an associate professor of health policy at the Yale School of Public Health and an associate professor at the Yale Institute for Social and Policy Studies, is an expert on health care access, particularly as it pertains to vulnerable populations. Ndumele’s research focuses on how government policies impact Medicaid enrollees and how changes in insurance coverage affect people with chronic physical and mental health conditions.

Dr. Ndumele recently looked at the long-term stability of enrollment in Medicaid among people in Michigan. The study appears in the Annals of Internal Medicine. Yale School of Public Health colleagues Anthony Lollo, a data scientist, Dr. Harlan Krumholz, MD, Professor Mark Schlesinger, and Assistant Professor Jacob Wallace are co-authors of the study.

What was the impact of long-term stable enrollment in Medicaid among the Michigan beneficiaries you studied?

C.N.: Our study was designed to examine the stability of Medicaid coverage for low-income beneficiaries. Medicaid, which now covers 95 million Americans, has long been described as a safety-net program, with the connotation being that the program is a temporary stopgap for people in hard circumstances. One of the challenges associated with the framing of Medicaid exclusively as a safety net is that it limits the perceived need for investment in the program, especially among the private (and often for-profit) partners that largely facilitate access for beneficiaries. For example, private partners are more likely to encourage the use of preventative services if they believe they will reap the benefits of such an investment. Evidence suggests that growing income inequality, limited social mobility, and the expansion of Medicaid by increasing income thresholds for eligibility have grown the program, but no recent work had demonstrated whether those changes have impacted the long-term stability of health insurance coverage for low-income families.

To answer that question, we followed four million Michigan Medicaid beneficiaries who were in the program between 2011-2020 (a decade). Among a sample of 1.2 million beneficiaries who were enrolled in 2011, we found 53% remained enrolled in 2020. We also, however, found high levels of instability among beneficiaries. While this cohort spent 67% of the decade in the program, only 25% percent of those individuals were enrolled continuously between 2011-2020. Taken together, Medicaid has become a primary and long-run form of insurance for most beneficiaries, suggesting it’s worthy of investment and providing ample opportunity to shape and improve outcomes for this vulnerable population. Yet, the instability of the program’s design undermines states’ capacity to do so.

What concerns do you have about the expiration of the Medicaid continuous enrollment provision?

C.N.: As I mentioned, although 53% of the individuals we studied were on Medicaid at both the beginning and end of the last decade, only 25% of those individuals were continuously enrolled over that period. In fact, it’s not uncommon to see eligible families temporarily lose coverage because they did not receive or fill out paperwork to recertify their eligibility. During the COVID-19 public health emergency, the federal government suspended states’ ability to drop individuals off the Medicaid roles for failing to recertify. With those provisions ending shortly, I am very concerned that millions of eligible individuals will endure at least temporary disruptions in coverage and access to care, which is bad for their health and inefficient for the system. We know that some of these individuals won’t re-enroll in the program until they encounter a preventable hospitalization, and some may forego acquiring coverage at all. Many of these families, who received Medicaid benefits for the first time during the COVID-19 period, have never gone through the recertification process. In addition to the practical benefits of Medicaid coverage, which include free preventative services, access to free or low-cost medications, and reductions in excess morbidity and mortality, having insurance coverage just gives people peace of mind.

Are states prepared for a return to routine operations and what can states do to promote continuity of coverage for those who may be impacted by the change?

C.N.: One of the most interesting features of Medicaid is that it is largely decentralized, so there is almost always tremendous variation in the preparedness of states as it relates to any challenge or circumstance. The good news in this circumstance is that states all have a wide set of tools available to avert this potential crisis. First, states can use their existing data systems to reduce the burden on beneficiaries. This means assessing eligibility from adjacent means-tested programs with similar income requirements (e.g., SNAP), using historical data to identify individuals and families at greater risk for dropping off the program and engaging in sustained outreach, and ensuring that recertification processes are as streamlined and easy to access as possible. Second, because not all individuals will continue to qualify for Medicaid, states also need to be proactive about ensuring that individuals who transition off the program don’t face significant disruptions in care. This means investing in navigators to help people identify the right health plans for them, ensuring meaningful overlap between providers who accept Medicaid and those who accept other types of insurance coverage, and ensuring that those insurance options are affordable.

Finally, because this is going to require both resources and coordination, limiting disruptions will require assistance from the federal government to help share best practices and ensure states don’t cut corners. I’m hopeful that states will be up to the challenge.

Submitted by Colin Poitras on March 16, 2023