Medicaid and the Public Health Emergency

A girl in her late teens – I’ll call her Cassie – recently enrolled in a Medicaid program I oversee that helps support people with asthma in North Texas. She reported trouble breathing and back pain to our nurse over the phone. Like many adolescents right now, she also had symptoms of depression and anxiety.

Our team connected her with a respiratory therapist to help her use her inhalers correctly. We made sure she got in to see her doctor. Our social worker referred her to a counselor. On a recent check-in call with her care manager, she reported improvement in her symptoms and adherence to her medications.

But her long-term success is tenuous. She could lose access to her doctor, her asthma medicine and her counselor in the coming months because she risks being cut from Medicaid.

On Jan. 31, 2020, then-Health and Human Services Secretary Alex Azar declared the novel coronavirus a public health emergency. U.S. citizens returning from China were told to quarantine, and eventually we faced widespread lockdowns, closed schools and businesses and mask mandates. Many people lost their jobs and found themselves uninsured.

One bright spot during this dark time was that people on Medicaid, the publicly funded health insurance program for low-income children and qualifying adults, were granted a reprieve from the reenrollment rules that require them to prove eligibility at least every 12 months. The Families First Coronavirus Response Act made more federal funds available to states – but only if they agreed to keep people on the Medicaid rolls until the emergency ended.

Enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has since reached an all-time high, increasing 19.1 percent since the pandemic began. Although benefits vary among states and health plans, most of the now-85 million people on Medicaid and CHIP (about one in four Americans), including Cassie, have access to medical care, some dental benefits, mental health services, medications, screenings, immunizations and, if needed, hospitalization.

Ironically, the end of the public health emergency, which is set for April 16, but likely to be extended to July, may stoke a new kind of crisis: 14 to 16 million low-income Americans are likely to lose their Medicaid coverage when going through the required redetermination process to see if they are still eligible.

Kay Ghahremani, president and CEO of the Texas Association of Community-Based Health Plans, doesn’t expect redetermination to go smoothly. “After more than two years of continuous Medicaid eligibility, people will not anticipate their need to re-enroll,” she said. “The consequences for millions of Americans with not renewing their Medicaid coverage could be dire if they or their children are getting treatment, have chronic conditions or suffer with mental illness.”

States have tough decisions to make when the continuous coverage requirement is lifted. They need to ensure systems – and well-trained staff — are in place to process large numbers of renewals and follow up with people who appear to be ineligible. According to a recent survey by the Kaiser Family Foundation (KFF) and the Georgetown University Center for Children and Families, many aren’t prepared.

Furthermore, Medicaid recipients may not be familiar with the redetermination process, especially if they were newly enrolled during the pandemic and haven’t had to recertify before. Missing or inaccurate information, such as outdated phone numbers, can jeopardize an application. They will need to be nudged to continue their enrollment, if eligible, or move to a better alternative.

Some people will find coverage through employment or the Marketplace created by the Affordable Care Act. Others may access limited benefits through government programs such as Healthy Texas Women, which provides annual exams and family planning services to low-income women aged 15-44 in Texas. But many will join the ranks of the uninsured.

To complicate matters, federal match dollars under the Families First Coronavirus Response Act that incentivized states to provide continuous Medicaid enrollment during the pandemic will expire 60 days after the end of the public health emergency. This creates a perfect storm by encouraging states to cut people from the Medicaid rolls as quickly as possible since they will no longer have extra federal money to help cover the cost of care.

People living in states that failed to expand Medicaid to most low-income adults – including my home state of Texas – are especially vulnerable. States should conduct robust outreach, starting now, to connect those who no longer qualify for Medicaid with alternative coverage.  The federal government has already advised states on how to make the redetermination process “flexible and friendly to consumers,” Ghahremani said. Keeping people covered should be the top priority.

Being uninsured in the U.S. is a high-stakes gamble. In my years of clinical practice, I saw the consequences on a daily basis: a woman with a much-delayed breast cancer diagnosis; a man with incapacitating anxiety who couldn’t afford his medicine, and a young man with severe abdominal pain who refused my referral to the ER because he knew he couldn’t pay the bill.

A health crisis can cause financial ruin. A survey released last summer by the U.S. Census Bureau showed that those without health insurance were nearly twice as likely to have medical debt (30.8%) as those with full coverage (16.2%).

People without insurance are more likely to forego preventive services and postpone needed care. Being uninsured also is associated with a lower life expectancy. Medicaid saves lives.

Medicaid coverage, however, is not a panacea. We need a long-term solution to the crisis of rising health care costs and large numbers of uninsured Americans that goes far beyond Medicaid expansion. The Affordable Care Act, which celebrated its 12-year anniversary last month, did not do enough to ensure universal coverage.

As we’ve learned from the pandemic, our interconnectedness places us all at risk when others get sick and can’t access care. Taking steps now to limit the disruption to the millions of families at risk of losing coverage is essential to their health, and ultimately, the health of all of us.

Lisa Doggett, senior medical director of HGS AxisPoint Health, is a columnist for Public Health Watch. The views expressed in her column do not necessarily reflect the official policy or position of HGS AxisPoint Health or Public Health Watch.