Health Care/Joan Retsinas

The Crack that Is a Chasm: Medicaid Unwinding

States have been dropping (a.k.a. “unwinding”) enrollees off Medicaid for the past year. During COVID’s ascendance, Uncle Sam forced states to expand their Medicaid rolls (the Families First Coronavirus Response Act [FFCRA]). Too many people were ill with a contagious sometimes fatal virus. The prudent course was to treat everybody who tested positive, who lived with somebody who tested positive, who was sick, who might become sick.

The entire United States population was vulnerable, but especially poor people — many of whom didn’t have health insurance, relied on a porous network of clinics that might have been an hour’s drive away and who needed medications that they could not afford. Add to the mix the workers who lost their jobs, and insurance, during the lockdown. Equity and justice demanded that the country insure their health; COVID forced the move.

As we moved past COVID, states faced the decision: to drop those “expansion” enrollees? Or to keep them on the rolls? The budgetary hawks opted for “drop.” Conservatives who disliked government programs, (but not Social Security or Medicare), opted for “drop.” For taxpayers who knew no poor people (other than cleaning crews or baristas), the prudent decision was “drop.” States “unwinded” their rolls.

We now see what happened. April 1,2023, was the start-up day for unwinding. By April 4, 2023, states had dropped 19.6 million enrollees, the the Healthcare Financial Management Association reported.

By March 23 of this year, of the 94 million enrollees in Medicaid, 20.3 million had been “disenrolled” — 22% of the total. Another 44.4 million had had their coverage renewed. And 29.4 million — 31% — were awaiting decisions, in bureaucratic limbo. The key reason for the disenrollment: procedural. Applicants were trapped in bureaucratic snafus, including long delays in processing, misplaced forms, incorrect information, no person on the other end of the phone to answer questions. In fairness, some states extended the process, aimed to rectify the snafus. States, moreover, varied in their zeal to “unwind”: Utah “disenrolled” 57% of enrollees; Maine, 12%, KFF Health News reported.

Children fell through the crack-that-is-an-abyss. Seventeen states reported age distinctions: 65% of the disenrolled in Texas were children, compared to 20% in Oregon. Medicaid is a fluid program. Some people will go off the rolls as they gravitate to an employer plan, or to an Affordable Care plan. Yet others will go on the rolls for the first time.

As predicted, some enrollees signed onto an Affordable Care Plan. Those plans offered an insurance lifeboat, assuming would-be enrollees qualified, assuming that the administrators behind those plans made it happen. Sadly that lifeboat did not save many people. A few states made a herculean effort to smooth a transition: for people eligible for an ACA plan, New Mexico covered the first month and Rhode Island the first two months. Rhode Island, moreover, is one of four states that automatically enroll people “disenrolled” from Medicaid in an ACA plan, yet only 16% in Rhode Island and 9% in New Mexico ended up with ACA coverage, the Washington Post reported.

Overall, conservatives can cheer. The rolls dropped. Not surprisingly, states varied: Utah’s rolls dropped by 33%; North Carolina, by 0.9%. Hawaii was an outlier: its rolls rose by 0.8%.

Beyond the statistics are Americans, a lot of them, left without health insurance. We still have communicable diseases (measles is on the rise); we still have accidents; we still have debilitating diseases, like diabetes, hypertension, arthritis … Healthwise, we have abandoned many of our fellow citizens.

The question is: does anybody care enough to help?

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.

From The Progressive Populist, June 1, 2024

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