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Enrollment in the Medicaid program has swelled to nearly 83 million people since the onset of the COVID-19 pandemic.¹ This growth鈥攁n increase of approximately 17%鈥攈as been attributed to new enrollment of those experiencing pandemic-induced job losses and the continuous coverage provisions of the federally declared Public Health Emergency (PHE), which prohibits state Medicaid agencies from terminating coverage for most beneficiaries. With the provisions set to expire, it is projected that millions of beneficiaries may lose their coverage as states resume regular redeterminations of eligibility. In the absence of proactive measures from states and the federal government, access to care may be compromised for a broad swath of the US population, potentially compounding inequities laid bare by the COVID-19 pandemic.

Under the Families First Coronavirus Recovery Act (FFCRA)² passed in March 2020, states can qualify for a higher federal share of Medicaid costs during the PHE if they adhere to new maintenance of eligibility requirements that prohibit termination of coverage (all states have complied). As a result, while newly eligible beneficiaries were required to certify income and asset levels to enroll in the program, existing beneficiaries were exempt from the typical redetermination process. Before the pandemic, one-quarter of Medicaid beneficiaries changed coverage each year and most of these people experienced a temporary coverage gap. This churning (exiting and then re-entering the program) has been associated with disruptions in access to care and negative health outcomes.³

In their study published in JAMA Health Forum, Dague and colleagues⁴ used Medicaid administrative data from Wisconsin to decompose whether increases in the state鈥檚 Medicaid enrollment were driven by the FFCRA continuous coverage provisions or by the economic disruptions brought on by the pandemic. This analysis is timely and important for policy makers: the former (FFCRA provisions) would suggest states may experience a sharp spike in disenrollment when the PHE ends, rather than gradual changes in coverage as the economy improves. The authors used data from 2015 to 2017 to create a model of how 3 distinct cohorts of beneficiaries contributed to total enrollment each month: (1) those continuously enrolled; (2) those who churned; and (3) those newly enrolled. Then the authors tested how well that model predicted enrollment before the pandemic (2018-2019), and then used the model to construct a counterfactual level of enrollment in 2020 that both accounted for pandemic-related income shocks as well as decreased program exit among those experiencing recession-related shocks.

In Wisconsin, Medicaid enrollment increased 13% from March to September 2020. In their counterfactual modeling, Dague and colleagues⁴ found that historic enrollment patterns, economic shocks, and reduced program exit owing to the recession would explain an enrollment increase of only 6%. The remainder of the observed increase (approximately 7%), the authors concluded, was a function of increased retention related to the FFCRA eligibility provisions. These findings suggest that Wisconsin will experience a substantial disenrollment from the Medicaid program after the PHE and its continuous coverage provisions expire.

Dague and colleagues⁴ are explicit about 2 key limitations associated with their work. First, the study focused on just 1 state, one which had a 鈥減artial expansion鈥� of Medicaid eligibility that covered adults up to 100% of the federal poverty level. Therefore, these results may not fully extrapolate to other states, particularly those that fully expanded eligibility under the Affordable Care Act. Second, the study assumed that the historical relationship between unemployment and Medicaid enrollment has largely held true during the COVID-19 pandemic. While it is possible that the pandemic-induced job losses may recover at a different rate than in the past, the findings broadly align with other recent work⁵ showing little association between unemployment and Medicaid enrollment during the pandemic.

Although estimates suggest that as many as 15 million people in the US may lose their health care coverage when the PHE ends and Medicaid programs are obligated to resume redeterminations of eligibility, states have several tools available to mitigate potential disruptions in health insurance coverage and care.⁶ The first tool involves using existing data systems to reduce the burden on beneficiaries. Most states have already reduced the frequency of eligibility redeterminations, hoping to limit the number of eligible households that may lose coverage for failing to complete paperwork. States are also mandated to conduct redeterminations ex parte, using all available data sources (eg, Supplemental Nutrition Assistance Program enrollment) to assess eligibility before requiring beneficiaries to take action. As an additional step, states can use historical eligibility and enrollment data to identify populations at high risk for churn and engage them with outreach to proactively avoid disruptions in coverage. For individuals who must actively recertify, states can reduce administrative barriers by offering multiple methods for renewal, as well as streamlining, where appropriate, the application process.

Because Medicaid is designed to be countercyclical and responsive to changes in circumstances, some beneficiaries will not be eligible for the program after the PHE. States also have tools to minimize disruptions in access to care for these individuals. For example, states can work now to communicate with these beneficiaries about options for subsidized coverage available on state insurance marketplaces. States can also invest in navigator programs and partner with managed care plans and community-based organizations to facilitate information sharing and enrollment. Importantly, efforts to minimize disruptions in coverage may not fully eliminate disruptions in care. In particular, there is no inherent guarantee that health plan networks in Medicaid overlap meaningfully with networks in plans on state marketplaces. To the extent possible, states and insurance navigators should provide beneficiaries with information on in-network availability of key health care practitioners and services in any new forms of coverage.

There are several steps that the federal government can take to support and encourage these state actions. One option, as proposed in the Build Back Better Act, recently passed by the US House of Representatives (HR 5376),⁷ is to make available an enhanced federal Medicaid match rate to support these activities and to provide an incentive for states to minimize disruptions. Under this legislation, the enhanced Medicaid funding is available only to states that take several specific steps to avoid unnecessary disenrollment. For example, HR 5376 requires states to make 鈥済ood faith efforts鈥� to update beneficiary contact information by coordinating with managed care organizations and other entities; states may terminate coverage for nonresponse only after 2 failed attempts to reach a beneficiary using 2 different modalities; states are required to stagger redeterminations over a 12-month period; and states must provide monthly reports on redetermination activities. Resources for engaging in this work vary considerably among states and inequities in health coverage and access may grow in the absence of meaningful federal support.

The findings of Dague and colleagues⁴ together with other recent projections suggest that millions of people in the US may lose Medicaid coverage when the PHE鈥檚 continuous coverage provisions end. Along with support and encouragement from the federal government, states should invest now in the data processes, communications, and direct outreach needed to minimize Medicaid disenrollment among those who will likely remain eligible, as well as to quickly and efficiently transition ineligible beneficiaries to other forms of health insurance coverage.

Published: February 4, 2022. doi:10.1001/jamahealthforum.2021.4743

Open Access: This is an open access article distributed under the terms of the CC-BY License. 漏 2022 Schpero WL et al. JAMA Health Forum.

Corresponding Author: Chima D. Ndumele, PhD, Department of Health Policy and Management, Yale School of Public Health, 60 College St, New Haven, CT 06520 (chima.ndumele@yale.edu).

Conflict of Interest Disclosures: Dr Schpero reported receiving grants from the Commonwealth Fund, the Laura and John Arnold Foundation, the Milbank Memorial Fund, the US National Institute on Aging, the Patient-Centered Outcomes Research Institute, and the University of Pennsylvania, all outside the submitted work. No other disclosures were reported.