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Hundreds of thousands of Americans are losing Medicaid every month

Medicaid’s “Great Unwinding” is even worse than experts expected.

A staged photo of a spiral notebook labeled “medicaid” surrounded by a book, pens, a stethoscope, and a folded pair of glasses.
At least 363,000 people lost Medicaid last month. That number is going to grow.
Getty Images/iStockphoto
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Hundreds of thousands of Americans lost their Medicaid benefits in April, as emergency pandemic provisions that kept people enrolled over the past few years began to end. The coverage losses are going to only grow.

In Florida, nearly 250,000 people lost Medicaid coverage in April, as states began a process to check whether everyone currently enrolled in Medicaid still meets the eligibility criteria. About 73,000 people were also deemed ineligible in Arkansas. Another 53,000 had their coverage terminated in Indiana and 40,000 were removed from Medicaid in Arizona.

Policy experts and advocates warned before the eligibility checks began that people who are still eligible for Medicaid could lose their insurance due to administrative problems, such as not receiving mail from the state or not returning documentation to confirm they are still eligible. Now the early evidence suggests that’s exactly what is happening.

In Florida, for example, more than 80 percent of people who were dis-enrolled from Medicaid were kicked off for procedural reasons. About the same share of people who lost coverage in Arkansas and Indiana were deemed ineligible because they failed to report information to the state or because the state could not reach them. Only a small percentage of people — about one in seven in Arkansas — were removed because they were no longer eligible (i.e., their income had grown to the point it exceeded Medicaid eligibility limits).

“Too many people are falling through the cracks in the system,” Alison Yager, executive director of the Florida Health Justice Project, said. “This should be of grave concern to all those charged with protecting the health of our residents.”

The coverage losses were years in the making. During the pandemic, Congress provided additional funding to states so they would maintain what’s called “continuous coverage.” That meant states stopped their periodic checks of people’s Medicaid eligibility and everyone on the program remained eligible, even if their income or life circumstances changed. In part as a result, Medicaid enrollment had ballooned to more than 90 million Americans by the start of this year.

But the public health emergency is over. Every state is beginning to check the eligibility of every Medicaid recipient. As of April, states were allowed to start kicking people off the program and a handful of states started those dis-enrollments. Most other states will start doing the same by July.

Now some experts, alarmed by how many people are already losing coverage, are saying states should slow down. Yager said that Florida should stop dis-enrolling people from Medicaid until the state can figure out what has gone wrong. Joan Alker, the executive director of the Georgetown Center for Children and Families, urged the same in a blog post on the data. She pointed out that because Florida has not expanded Medicaid under the Affordable Care Act, the people losing their benefits are more likely to be children, parents, and young adults moving off their parents’ health insurance plan than in states that do have the expansion in place.

Alker ticked through the questions state officials should be asking themselves now: “Are families actually getting the renewal packet? Are they having trouble getting through to the call center for help? Has their eligibility been properly assessed?”

Policy experts predicted long before redeterminations started that administrative hurdles would lead to people losing benefits. States had months to plan for this possibility and try to figure out how to prevent it — and yet even in the first month, the coverage losses have already been significant.

Some people losing Medicaid coverage was inevitable — but not this many

A lot of people were going to lose their Medicaid coverage during the redetermination process, known among wonks as the “Great Unwinding,” no matter what. Some people found a new job with higher pay in the past few years and would have become ineligible sooner if states were checking eligibility as often as they usually do. Others were eligible because of their life situation — being a parent of a minor, for example — and that may have changed over the past few years, too. But those people were allowed to hold onto Medicaid because of the continuous coverage provision.

That coverage, and the growing number of Medicaid enrollees, helped to drive the US uninsured rate to record lows — but it was also never going to last. Medicaid isn’t intended to be a permanent universal health care program, and the federal government isn’t prepared to indefinitely spend the money it had been contributing to help states handle the influx.

But the goal was to minimize the unnecessary coverage losses as much as possible. Advocates hoped to see an extensive outreach campaign, to make sure the people on Medicaid knew about the redetermination process and were prompt about returning information to the state, and sufficient investment to make sure Medicaid offices were capable of handling the immense paperwork. For people who are genuinely no longer eligible, states were urged to connect them to the ACA marketplaces where they might qualify for financial assistance to purchase private coverage.

The early enrollment data suggests some states are failing dramatically at those goals. When the health policy think tank KFF estimated how many people could lose their Medicaid coverage during the Great Unwinding, the worst-case scenario was that 28 percent of people whose eligibility was checked would lose their insurance, a figure known as the dis-enrollment rate. (The best-case scenario was just an 8 percent attrition rate.) That rate, they projected, would lead to 24 million Americans would losing Medicaid benefits, including 7 million children.

In Florida and Arkansas, during the first month of redeterminations, more than 50 percent of people whose eligibility was checked lost their Medicaid benefits. (Arizona was more in line with expectations, with a 17-percent dis-enrollment rate in April.) That initial data suggests coverage losses could be even greater than feared.

Anecdotal evidence reveals Medicaid enrollees have found the process for confirming their Medicaid eligibility confusing and cumbersome. The Associated Press reported on one family in Florida who was told by a state website that their family, including a young son with cancer, would lose Medicaid coverage. Then another online form told them their benefits would continue. A letter sent through the mail said the parents would lose coverage while the son would keep it. It took three phone calls and six hours spent on hold for the family to finally get the real answer: The parents would lose Medicaid, but the son would hold onto it. Other enrollees in Florida didn’t learn they had lost coverage until they were at the doctor receiving medical care.

These were the kinds of scenarios that months of preparation were supposed to prevent — but now that the Great Unwinding is here, it’s clear a lot of people are falling through the cracks.

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