Amidst the optimism of pandemic relief, harsh reality slams at people’s front doors as its aftermath continues to manifest in various forms of collateral damage, including the millions who will be left uninsured through the Medicaid disenrollment process.
The public health emergency of COVID-19 initiated a cascade of effects, not the least of which being the closure of thousands of businesses, leading to an unemployment crisis. Terminations commencing in February 2020 equaled 984,333 job losses and advanced to 23 million by April 2020, according to a report by Georgetown University.
Under normal circumstances, unemployment is often accompanied with the loss of health insurance. To counteract this loss, Congress enacted the Families First Coronavirus Response Act on March 18, 2020, to help Americans retain coverage.
The FFCRA enhanced federal funding with a 6.2 percentage point increase in federal match rate in exchange for the Medicaid program to continuously enroll people until the end of the public health emergency. As a result, the number of people insured under Medicaid was estimated to grow from 23 million in February 2020 to 95 million by the end of March 2023, according to a report from the Kaiser Family Foundation.
Continuous enrollment came to an end by April 1 and the public health emergency formally ended on May 11.
It is estimated that between 7.8 million and 24.4 million people across the nation could lose Medicaid coverage during the 12 month unwinding process, as states return to their normal procedures of determining eligibility based on income and enrolling in their Medicaid programs.
What is Medicaid?
Medicaid is a program jointly financed by the federal government and state governments, providing health insurance to low income families. States are subsidized by the federal government to administer Medicaid programs with the liberty of determining how the care itself is delivered under federal standards.
The amount of federal matching dollars a state is qualified for is determined by the services they provide along with the state’s per capita income. In Arizona, for every dollar the state pays for its Medicaid program, the federal match is $2.
The Affordable Care Act plays an important role in the funding aspect of Medicaid. The ACA was established in 2010 by the Obama administration. It aimed to increase the eligibility criteria for Medicaid by expanding eligibility of adults with incomes up to 138% of Federal Poverty Levels, $14,580 annually for an individual in 2023, to decrease the coverage gap.
However, Medicaid expansion is not mandatory for states. Currently, 10 states across the country have not implemented Medicaid expansion, resulting in around 1.9 million people who fall under the coverage gap, a gray area where one is earning “above their state’s eligibility for Medicaid but below poverty,” according to the Kaiser Family Foundation.
Nearly 95 million people are under this entitlement program, and this program is particularly important to children who live in families with an income of less than 100% of the FPL as eight in 10 children in poverty rely on this service. Additionally, one in six adults and more than half the adults in poverty are enrolled with Medicaid, according to the Kaiser Family Foundation.
This program also covers 43% of nonelderly, noninstitutionalized adults with disabilities, 41% of all births in the country, half of children with special needs, five out of eight elderly in nursing homes and more, as reported by the Kaiser Family Foundation.
In addition to this, Medicaid offers coverage for many health and long term services that other programs do not cover. Some of these services include covering prescription drugs, dental care, early periodic screening diagnosis and treatment for children, non emergency medical transportation, certified pediatric practitioners, rural health clinic services, screening services and much more.
Overall, research concludes that Medicaid beneficiaries are able to better access care than those who are uninsured, based on the data collected by the Kaiser Family Foundation.
Effects of the disenrollment process
The Centers for Medicare and Medicaid Services requires states to submit renewal redistribution plans describing how the state will prioritize renewals and what strategies they will use to reduce unwarranted coverage loss. Like many other states, Arizona took its first steps to maintain up-to-date contact information of enrollees prior to the disenrollment process that began April 1.
The Arizona Health Care Cost Containment System and the Department of Economic Security have sent over one million notifications to members by text, email, phone call, and written letter about the renewal process.
However, despite these efforts, many enrolled in Medicaid do not receive information about the disenrollment process as they have changed locations, have not updated their contact information, have language barriers, have not completed the renewal packet within the given period and other factors. This has resulted in 72% of people disenrolled having their coverage terminated because of procedural reasons despite being eligible for Medicaid based on their low incomes, according to the Kaiser Family Foundation.
As the KFF reported, to combat unnecessary disenrollment, states seek complete administrative renewals by verifying ongoing eligibility through available data sources like state wage databases, known as ex parte, “before sending a renewal form or requesting documentation from the enrollee,” reducing the burden to maintain coverage.
Arizona has been executing renewals through the ex parte procedure. As of September, 89% of people in the state who kept their Medicaid coverage did so because of ex parte.
As of Sept. 15, 6,591,000 people have been disenrolled from Medicaid across 48 states, with about 289,100 disenrolled in Arizona alone.
Safety net health provider sites will be affected, including the 21 community health centers systems along with the 172 federally qualified health centers across the state. “They tend to take care of the low-income and uninsured groups of people,” said Dr. Daniel Derksen, professor of public health, medicine and nursing at the University of Arizona.
Additional groups affected include critical access hospitals, small hospitals with 25 beds or less, rural health clinics, Indigenous health services and tribal-operated services. These institutions heavily rely on the revenue from Medicaid-insured individuals, but when 10% of people are removed from the redetermination process, it causes a ripple effect. Hiring staff becomes more arduous, and the federally funded programs have to assume a greater burden of charity care.
The subset of individuals that will be most affected by this whole process are those who lost coverage. “The estimate was up to 500,000 could lose coverage during this redetermination process and so we are halfway there to the estimate,” Derksen said. The good news, however, is that many of the individuals who are disenrolled qualify for “[…] either no cost sharing or low cost sharing insurance through the Affordable Care Act,” Derksen said.
Medicaid re-enrollment assistance
State and nationally certified assisters and navigators help people determine what they are eligible for and transition to healthcare through the ACA marketplace or re-enrolling within Medicaid.
Of the many assisters and navigators in the state, Maria Losoya, a health educator and community outreach specialist for the Arizona Center for Rural Health, provided insight about her work during this time and her interactions with the community.
Losoya said that she gets many calls from patients including one exclaiming “I didn’t know, I went to the doctor and they would not cover my son’s treatment.”
Losoya, while the child was in the hospital, began to fill out an application through AHCCCS helping the family to re-enroll in the Medicaid program as their family income was below the 138% FPL.
However, “not everybody has the same opportunity,” and so this work requires lots of outreach to spread awareness about the current disenrollment, according to Losoya.
As a certified assistant, Losoya is consistently working directly with the community through radio station programs speaking both in Spanish and English, providing information in newsletters, distributing flyers and hosting events/presentations. Losoya also speaks directly to the community about the marketplace, who qualifies for AHCCCS, how and where to apply and more.
As a result of these various forms of outreach, Losoya receives many calls and messages seeking assistance. One way to receive aid is through the Cover Arizona website by clicking on the “Find Help” button.
“I enroll people into health insurance plans with zero monthly payments, zero deductibles, medications to dollars, primary doctor $20, specialists $35, so very affordable and they have very good plans as the government provides these plans based on the income, family size and age,” Losoya said.
Arizona has also taken the initiative to educate families about health insurance within school systems. Losoya shared a story about a mother who did not have any health insurance and had called the school nurse regarding her child’s fever. Now nurses have the ability to check the family’s insurance status and the school then provides education and directs the family to places they can go to apply for insurance.
Losoya goes to teacher conventions to educate the teachers from various counties about Medicaid and health insurance, so when they go back to their communities they too can pass on the information to families.
So far out of the total planned 2,545,454 renewals, 32% have been approved, with 17% in the midst of renewal, 40% of renewals remaining and 11% of renewals discontinued according to the AHCCCS.
To promote an increased rate of certified assisters at the federal level, there is a grant program under the Health Resources and Services Administration that provides navigator support. The HRSA awarded another contract to the Arizona Alliance for Community Health Centers, a primary care association for the state, providing individuals with resources so one can become a certified assistant.
The University of Arizona Center for Rural Health provides opportunities for students to become certified assisters through the Students Helping Arizona Register Everyone program to help members of communities to navigate the online healthcare system as well as be involved with the rural communities through the Arizona Area Health Education Centers.
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