State health officials are looking to Congress for help, as millions of people are in jeopardy of losing Medicaid coverage when the federal government declares an end to the COVID public health emergency.
It has been extended 11 times since the declaration was first made in January 2020. States expect another extension, keeping it in place until at least April, but they have been left guessing as they strive to plan for its conclusion.
At issue are provisions in the first COVID relief package passed by Congress in March 2020 that prevented states from removing recipients from Medicaid rolls and provided extra federal money until the virus was brought under control.
Those provisions contributed to a historic rise in the number of Medicaid and CHIP enrollees. They also created a massive logistical challenge for state health officials, who have been tasked with coming up with plans to resume normal operations and limit coverage losses under a constantly shifting deadline.
“Even the most well-intentioned state is going to find this challenging when this happens,” said Joan Alker, executive director of the Center for Children and Families and a research professor at the Georgetown McCourt School of Public Policy. “When you think about it, this is approximately a quarter of the U.S. population that has to have their health insurance renewed over a period of time. … It’s a mammoth task.”
The federal government estimates that as many as 15 million people could lose their Medicaid coverage at the end of the public health emergency, including almost 7 million who would still be eligible for it.
State health officials and public health experts say those losses could be reduced if Congress addresses the issue in an end-of-year spending package that must pass before Dec. 16 to avoid a government shutdown.
Chief among their requests is a specific date for the end of the Medicaid continuous enrollment requirement, with advance notice that will allow states to plan. The Department of Health and Human Services has promised to give states 60 days’ notice before letting the emergency expire, but public health advocates say they need more time, with requests ranging from 90 to 120 days.
Congress could also gradually phase out the extra money the federal government has provided to the states during the pandemic — a 6.2% increase in enhanced federal funding that’s available through the quarter in which the public health emergency ends. States also want an assurance that underlying Medicaid eligibility rules will not change during the redetermination period.
Jamie Munks, a spokeswoman for the Illinois Department of Healthcare and Family Services, said the extra funding has been welcome, but “the repeated revamping of schedules to accommodate resuming redetermination activities is confusing to customers, providers, advocates and managed care plans, and jeopardizes the ability of state government to staff this function appropriately.”
Anthony Cava, a spokesman for the California Department of Health Care Services said the uncertainty surrounding the end of the public health emergency introduces new complexities in the state budgeting process.
“The duration of the PHE has a direct impact on caseload levels and the amount of increased federal funding the state receives,” Cava said. “State budgets are based on legislation enacted at a point in time based on the best assumptions available at that time. Uncertainty about the timing of when the PHE will end has meant that expenditure needs in the Medicaid program can change significantly only months after the budget is enacted, and could potentially require mid-year revisions.”
Other state requests include loosening restrictions on how states contact enrollees to inform them that they need to re-enroll for Medicaid and what their other coverage options are if they are no longer eligible. The Telephone Consumer Protection Act prohibits marketing to consumers by phone or texts, but Medicaid enrollees, who are typically members of vulnerable populations, are more likely to have cell phones than reliable internet connections and stable home addresses, advocates say.
“We do not feel these health care priorities are terribly complicated or expensive, but they will make a real difference in the lives of citizens,” said Ceci Connolly, president and CEO of the Alliance of Community Health Plans, one of a number of advocacy groups that has sent letters to Congressional leaders urging them to act during the Lame Duck session. “We are very optimistic that we can have these flexibilities and glide paths included in the legislation.”
The Build Back Better Act, which passed the U.S. House in 2021 but stalled in the Senate, would have set dates to phase out continuous enrollment provisions and included rules to help those who remain eligible for Medicaid retain coverage.
Advocates and a congressional aide familiar with the negotiations said there is renewed energy to address the issue now, with the end of the COVID pandemic in sight and priorities likely to shift after Republicans take over the House in January.
Congressional leaders have heard the message and have bipartisan consensus on taking action before the end of the year, according to aides who spoke to Pluribus News on the condition of anonymity to protect the ongoing negotiations.
“There is a broad interest in having some sort of guidance set out so we can unwind the formal declaration without putting stakeholders in difficult positions,” a Republican aide said.
“Protecting the progress made with Medicaid coverage and ensuring that vulnerable populations do not lose coverage is a top priority,” a Democratic aide said. “When the House passed the Build Back Better Act it included a number of provisions to establish guardrails to protect Medicaid beneficiaries. Democrats are working to include those coverage protections in the end of year package.”
There is also urgency for state officials to get some clarity, as most states are set to begin their legislative sessions and the budget-writing processes in January, said Jack Rollins, director of federal policy for the National Association of Medicaid Directors, a nonpartisan group that represents leaders of all Medicaid programs across the country.
The NAMD laid out its priorities in a letter to congressional leaders last month that called the end-date uncertainty “no longer tenable.”
“We don’t know what resources we need to deploy and over what timeline,” Rollins said. “It’s honestly beginning to erode the credibility that Medicaid leaders have with their key constituency in state government. There’s a sense of incredulity, like, how can you still not know?”