Of the 83 million Americans enrolled in Medicaid, nearly half being children, about 23 million have lost coverage since the pandemic, or stand to lose it.
The federal COVID-19 emergency froze the process of annual Medicaid eligibility checks known as redetermination. Since the emergency was lifted in May 2023, redetermination has begun again for the nearly one in four Americans and nearly half of all children in the country who are on Medicaid — worsening historic coverage gaps in many states.
Redetermination and coverage gaps
“Because of the bureaucratic hoops that people need to jump through, the past year has been like a disenrollment churn on steroids, even for many who are still eligible,” said Katherine Hampstead, senior policy advisor at the Robert Wood Johnson Foundation, at a Friday, August 9 Ethnic Media Services briefing on Medicaid coverage gaps.
69% of these disenrollments owe to paperwork issues rather than ineligibility, and nearly a quarter of the 20 million people dropped from Medicaid since the redetermination began are still uninsured as of April 2024.
“Medicaid is the largest single source of health insurance in the country, but there’s both federal and state money going into it … so it’s like 50 different programs state to state,” explained Hampstead, adding that redetermination is particularly worsening coverage gaps for the populations Medicaid was originally designed for, like low-income groups, seniors, people with disabilities, children and pregnant women.
Coverage gaps also disproportionately affect communities of color — especially in the 10 states, mostly in the South, which have not expanded Medicaid income limits from 100% to 138% of the Federal Poverty Level (FPL) for adults aged 19 to 64.
This FPL expansion is permitted by the Affordable Care Act, and was ruled by the Supreme Court in 2012 to be optional for each state.
As of 2024, the FPL is $14,580 for an individual, 138% percent of that being $20,783; or $24,860 for a family of three, 138% of that being $35,632.
In states which haven’t expanded FPL limits — like Florida, Texas, Georgia, Alabama and Mississippi — “there’s a coverage gap where two to three million people, predominantly populations of color, are in a very unfortunate situation where they’re ‘too poor’ to get marketplace subsidized coverage, yet they don’t qualify for Medicaid because their state’s eligibility limit is so low,” said Hampstead.
Youth coverage
“Despite our name, young people are not invincible,” said Martha Sanchez, health policy and advocacy director at youth advocacy nonprofit Young Invincibles. “We’re the future of our U.S. workforce and economy, and we cannot afford to continue to regress in our health.”
About 30% of U.S. young adults aged 18 to 34 are uninsured, higher than any other age group and comprising over one in five of all uninsured Americans.
Meanwhile, a 2019 CDC study shows that at least half of young adults have at least one chronic condition like diabetes, cancer or mental health issues.
Since the pandemic these conditions have only been rising, with one third of all young adults — and half of those aged 18 to 24 — reporting symptoms of mental illness.
The American Cancer Society also reports increasing rates of cancer among young adults; particularly types associated with older adults, like colon cancer.
“We’re in a crisis where our health care systems are not meeting the needs of our young people, who are often in a stage of transition out of Medicaid … because there’s no expansion, they’re sold student health plans or they don’t know how to enroll in other plans,” said Sanchez.
“I grew up on Medicaid, and I never understood all of the benefits I had until I transitioned out as a college student,” she explained. “I had annual checkups, vaccinations and dental care, but I had no idea about the mental health benefits. And we’ve heard this from other young adults who shared that they would have taken advantage of mental health resources, but had no idea it was covered … We need not only Medicaid expansion but health literacy, so people can actually use their coverage.”
Since redetermination, 5.5 fewer children below 18 are enrolled in Medicaid as of July 2024.
“Many of these children remain eligible, and we need to get them back enrolled, particularly in back to school right now,” said Joan Alker, executive director and co-founder of the Center for Children and Families and research professor at Georgetown University.
Net Medicaid enrollment changes vary drastically between states, with the largest drops by number being 1.3 million fewer children in Texas, approximately 542,600 fewer children in Florida and 373,000 fewer children in California.
The largest drops by percentage are Utah, with 34.5% fewer children on Medicaid; Colorado, with 30.9% fewer children; and Texas, with 29.1% fewer children.
“We’ve heard that parents are putting off care because they’re not insured, and just hoping their child doesn’t get sick. That children are having to skip their medications, not getting their inhalers and missing treatments for behavioral health conditions,” said Alker.
“Children are not expensive to our health care system, but they need regular care, so even a short gap exposes the family to large medical bills … and without that routine care, children are less able to learn,” she added. “Many of these children are still eligible for Medicaid. Any gap in coverage is not acceptable.”
What’s next?
“The price America pays for giving states enormous authority over their Medicaid programs is extremely high,” said Stan Dorn, director of the Health Policy Project at UnidosUS. “A family has a very different likelihood of getting health care based simply on the state in which they happen to live.”
To bridge these dramatic coverage gaps across states, Dorn suggested making “administrative burdens completely irrelevant for as many people as possible” through paperless eligibility; linguistically and culturally accessible enrollment help; automatic renewal of qualified people using tax and wage information that the government already has; and providing continuous coverage in the case of missing paperwork.
As states pay a percentage of the cost of each Medicaid enrollee, Dorn also suggested creating federal standards for state redetermination performance to incentivize states that don’t want to pay.
States that exceed standards would get a bonus, as was done with the Children’s Health Insurance Program in 2009. For states that don’t meet standards, he suggested deferring federal payments until the state improved, while stopping families from being terminated.
“We found that the states with the worst problems in terms of people losing coverage had invested the least amount of money in their eligibility infrastructure. So ultimately, it’s a question of values,” said Dorn. “Are the states’ officials willing to invest enough money in running a Medicaid program that they would trust with their own family’s health care? Some are willing to invest in systems that work for families and providers, and others are not.”
