KANSAS CITY, Mo. — In a closet-sized windowless office, Kialah Marshall maintains an Excel spreadsheet with a prosaic title, “Medicaid Unwinding,” the source material for a mind-numbing routine.
Five days a week, she and a group of co-workers in a poor section of Kansas City, Missouri’s largest city, call 75 to 100 Medicaid recipients from a list of about 19,000 who receive care at Swope Health, a federally funded network of health clinics. Their assignment is straightforward: warning those patients that they could lose their health insurance for the first time in at least three years.
“Medicaid is on the line,” Ms. Marshall, once a recipient herself, said in that cramped office last week, describing how she delivers the potentially dire news.
As of Saturday, state officials around the country could begin removing people from Medicaid who no longer qualify — something they had been prohibited from doing under a provision in a coronavirus relief package passed by Congress in 2020.
That package offered states additional federal funding in exchange for guaranteeing that recipients of Medicaid, a joint federal-state program that serves low-income people, would retain their health coverage during the pandemic. In part because of that policy, the nation’s uninsured rate reached a record low early last year.
Medicaid and the Children’s Health Insurance Program have ballooned to cover roughly 90 million people, or more than one in four Americans — up from about 70 million people at the start of the pandemic. The guaranteed coverage amounted to an extraordinary reprieve for patients, preserving insurance for millions of vulnerable Americans and sparing them the hassles of regular eligibility checks.
The federal government has estimated that about 15 million people will lose coverage in the coming months, including nearly seven million people who are expected to be dropped from the rolls even though they are still eligible. Nearly half of those who lose coverage will be Black or Hispanic, according to federal projections.
The changes in eligibility could lead to more people signing up for private coverage through the Affordable Care Act’s marketplaces, where some people who lose Medicaid coverage will be eligible for free plans.
But hundreds of thousands of people could end up in the so-called coverage gap in states that have not expanded Medicaid under the Affordable Care Act, with incomes too low for subsidized coverage through those marketplaces but too high to qualify for Medicaid.
The speed and mechanics of what Ms. Marshall and state and federal health officials are calling the “unwinding” will vary by state. A majority of them plan to take 12 to 14 months to complete the eligibility verifications, with many states beginning to remove people from Medicaid rolls by late spring or early summer. Only five states — Arizona, Arkansas, Idaho, New Hampshire and South Dakota — were expected to begin axing people from Medicaid this month, according to the federal government.
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Some state officials have argued that the program is merely retreating to its intended size and shape. “We’ll be able to go back in there and say, ‘OK, do you belong? Do you not belong?’” Gov. Michael L. Parson of Missouri, a Republican, said in February.
Annual eligibility checks can save states money by relieving their Medicaid programs of spending on participants who no longer qualify for coverage. But they often result in a cycle that health policy experts call churn, or when people eligible for Medicaid lose their insurance in the confusing, intimidating bureaucracy of enrollment verification, then eventually re-enroll.
“Those people don’t have anywhere else to go,” said Jennifer Tolbert, an associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. She added that the consequences would be severe for people with chronic health conditions for whom a week or a month without insurance could be especially risky.
Researchers have found that most people who lose Medicaid coverage often go without insurance for some period of time, while about four in 10 regain Medicaid coverage within a year.
In Missouri, where state officials have warned that as many as 200,000 people may lose coverage, the unwinding could result in a boom-and-bust cycle.
The state expanded Medicaid under the Affordable Care Act during the pandemic, resulting in more than 300,000 new adults with coverage. It now has about 1.5 million Medicaid recipients, half of whom are children.
That growth makes the state a proverbial canary in the coal mine for the rest of the country during the unwinding, said Timothy D. McBride, a health policy expert at Washington University in St. Louis and the former chair of an oversight committee for the state’s Medicaid program. He pointed to a controversial period in 2018 and 2019, when officials used a new process for verifying Medicaid eligibility to remove over 100,000 people from the rolls, many of them children. That led to complaints of unjust removals.
“Have we learned lessons from that period?” Dr. McBride asked.
Medicaid eligibility rules vary by state. They can depend on a family’s income, whether someone is raising a child and whether a person has a disability. Millions of children and pregnant women benefit from the program.
For states, tracking down those who are on Medicaid will be daunting, experts say. Some people will have moved, and some will have died. Phone numbers will have changed, making some people hard to reach. Others will be earning more, making them ineligible for coverage.
Researchers at the Kaiser Family Foundation and the Georgetown University Center for Children and Families found different strategies among states, some of them with spottier technology that could hinder efficient re-enrollment. Most states, the researchers found, were using databases from other government programs, such as food stamps or Social Security, to verify eligibility for Medicaid automatically and save people the hassle of filling out paper forms. Missouri has adopted that strategy.
The so-called continuous enrollment policy requiring that Medicaid recipients retain their coverage was initially set to end with the expiration of the public health emergency for the pandemic, which the Biden administration is planning to allow to lapse in May. But before the administration announced its plans to end the emergency, a spending package that Congress passed in December separated the Medicaid policy from the emergency declaration and established an April 1 starting point for the unwinding.
When lawmakers set that date, they attached guardrails to encourage states to undertake the work gradually. The legislation mandates that states report data monthly to the Department of Health and Human Services on how many people have been taken off Medicaid. It also allows the department to intervene if a state does not comply with federal requirements.
Missouri is starting with people whose coverage would be up for renewal in June, a group of about 100,000. The state is leaning on managed care organizations to work with Medicaid recipients on renewals, but the effort required of the state is still immense. Kim Evans, the official overseeing the Medicaid unwinding in Missouri’s Department of Social Services, said she had about 1,200 government workers available to help.
Those whose status the state is still uncertain about after automatic checks will be mailed letters early next month, and they will have until the end of June to complete renewal forms. If they miss that deadline, they will lose their insurance, but they can still challenge the decision and be re-enrolled if state officials determine them to be eligible.
Ms. Evans called the work an “all-out assault” to reach people who might otherwise slip through the cracks.
Sidney D. Watson, a health law professor at Saint Louis University, said the unwinding could be particularly damaging to the many seasonal agricultural workers in rural stretches of the state, like in the Ozarks. “Everyone is on high alert here,” she said, adding that Medicaid coverage among those seasonal workers was important to keeping smaller hospitals and clinics running.
Clinics like Swope Health are especially critical to warning Medicaid recipients about the unwinding policy, since their doctors and other health providers often know people affected by the policy change. Swope has run radio ads and placed billboards in and around Kansas City, which have increased calls from Medicaid recipients inquiring about how to preserve their insurance, said Tamika Reliford, one of Ms. Marshall’s co-workers who helps patients with their coverage.
Almost half of Swope’s roughly 40,000 patients are covered by Medicaid or the Children’s Health Insurance Program, meaning the clinics rely on Medicaid funds. “We still have to employ the providers, the nurses and administrators here to do the hard work,” said Jeron Ravin, Swope’s chief executive.
For some Swope patients unaware of the unwinding, it takes a lucky encounter. Unable to get Medicaid to cover his eye-drop prescription for glaucoma in recent weeks, Derrick Smith learned something more important when he asked Swope for help: He could eventually lose his coverage altogether.
Checking Mr. Smith’s Medicaid status, Ms. Reliford noticed he had moved, making him vulnerable to missing a mailing about the unwinding if one was sent to his previous address. Mr. Smith had not heard about the eligibility check.
“I was real close on it,” he said sheepishly while visiting a Swope clinic last week, adding that losing his insurance would have been an “easy mistake” for him to make.
Mr. Smith was one of the hundreds of thousands of adults who secured Medicaid coverage when Missouri expanded the program under the Affordable Care Act during the pandemic. But like others who gained coverage that way, he will be getting his first glimpse of annual scrutiny of his eligibility.
Ms. Marshall, the Swope employee working through the Medicaid spreadsheet, said she worried about sending patients into a state of “frantic panic” when she reaches them to warn about the possibility of losing coverage. “This is something that a person needs,” she said, “for their family, for their children.”