The End of the COVID Public Health Emergency: Potential Health Equity Implications of Ending Medicaid Continuous Coverage
Patricia Boozang and Adam Striar, Manatt Health
Medicaid enrollment has increased by over 10 million (or 15 percent) from February 2020 through February 2021 across all states since the outbreak of the COVID-19 pandemic. A significant contributor to these gains in coverage is the Families First Coronavirus Response Act (FFCRA) “continuous coverage” requirement, which limits the ability of states to disenroll individuals from Medicaid. Following the end of the federal public health emergency (PHE), states will no longer be subject to this requirement, which could potentially result in widespread disenrollments from Medicaid and jeopardize health care coverage and access for millions of low-income individuals.
States have a clear imperative to center health equity as they plan for the end of the PHE given that Black, Latino/a, and other people of color are most at risk of coverage loss. People of color are overrepresented in the Medicaid program and are more likely to experience volatility and instability in employment and housing as a result of longstanding, structural racism, thus increasing the chances that these individuals could lose coverage for administrative reasons at the end of the PHE. This comes as Black and Latino/a individuals are experiencing the worst impacts of the pandemic–Black and Latino/a individuals are more than twice as likely to have been hospitalized or to have died as a result of complications from COVID-19. Maintaining coverage is critical to ensuring access to care during the ongoing pandemic, including for deferred care for chronic conditions. In order to optimize coverage retention and access to health care at the end of the PHE, state and federal leaders need to be working now to employ a range of strategies that streamline and improve their redetermination processes. This expert perspective highlights the urgency and specific recommendations for states to retain coverage gains for Medicaid-eligible individuals at the end of the PHE, and ensure that coverage retention efforts include an equity focus.
Passed by Congress in March 2020, FFCRA was intended, in part, to shore up state finances by temporarily increasing the federal share of Medicaid funding for states. To protect health coverage during the pandemic, states were prohibited from disenrolling individuals from Medicaid for the duration of the federal PHE as a condition of accessing the enhanced funding. This “continuous coverage” requirement extends from March 18, 2020, through the end of the month in which the PHE ends. In January 2021, the Biden administration announced that the PHE will likely remain in place through the entirety of 2021, meaning the continuous coverage requirement will likely remain in effect at least through the end of this year.
In a typical annual redetermination process, some number of enrollees lose Medicaid coverage due to changes in circumstances that impact eligibility (e.g., income increases). More commonly, Medicaid eligible people “churn” at redetermination–or lose coverage as a result of administrative barriers like a lack of online options for renewing coverage, complicated paperwork and documentation processes, and personal circumstances that prevent individuals from responding to a renewal request on time (these challenges are particularly acute for individuals with significant health needs). Evidence suggests that churn–and not external factors like an improving economy driving income ineligibility for Medicaid–have been the primary sources of Medicaid enrollment decreases in recent years. The FFCRA continuous coverage requirement effectively eliminates churn in Medicaid for the duration of the PHE.,
Following the expiration of the PHE, states will resume normal eligibility and enrollment activities and begin to redetermine Medicaid eligibility for all enrollees, some of whom have not had to go through this process in nearly two years (including some who have never had to redetermine their Medicaid eligibility because they enrolled during the pandemic or shortly before it began). The Centers for Medicare & Medicaid Services (CMS) released guidance that describes timelines and obligations for states to restart eligibility and enrollment activities following the end of the PHE. This guidance attempts to help mitigate coverage disruptions by giving states 12 months to complete the “PHE unwinding” process and requiring robust consumer communication, among other strategies. CMS has reiterated that states should pursue eligibility and enrollment strategies that promote continuity of coverage and ensure that enrollees have ample time to respond to requests.
But there is still considerable risk of coverage loss following the end of the PHE due to the coverage churn that is so prevalent in Medicaid, despite the fact that the vast majority of people enrolled in Medicaid at the end of the PHE are likely to remain eligible for Medicaid or be eligible for subsidized ACA Marketplace coverage. Black, Latino/a and other people of color enrolled in the Medicaid program face disproportionate risk of loss of coverage due to churn.
Implications of the End of the PHE for People and Communities of Color
Large scale disruption in health coverage as a result of the expiration of the federal PHE will have disproportionate impact on Black, Latino/a, and other people of color, who are significantly overrepresented in state Medicaid programs. Despite making up less than a third of the total United States population in 2019, more than half of Medicaid and CHIP enrollees were Black or Latino/a. (See Figure 1.) Since Black, Latino/a and other people of color make up the largest share of Medicaid enrollees, they will necessarily bear the most significant impact of any large-scale coverage losses at the end of the PHE.
Longstanding, structurally racist policies and practices in the United States have created an environment where Black, Latino/a and other people of color experience a significantly greater degree of volatility in employment and housing – conditions that will exacerbate the coverage impacts at the end of the PHE. Even before the pandemic, Black and Latino/a individuals were more likely to work in service sector professions and experience a greater degree of month-to-month income volatility. This is largely driven by historical and ongoing discrimination in employment, education, and other social systems. Black and Latino/a individuals are also significantly less likely to own their homes and more likely to face steep rental costs, which has its roots in myriad historical and ongoing racist policies excluding people of color from desirable housing (e.g., “redlining”). Black, Latino/a and other people of color have borne the worst economic impacts of the pandemic. While the unemployment rate in 2020 increased by only 1.8 percentage points for white individuals, it increased by 3.2 and 3.5 percentage points for Black and Latino/a individuals, respectively. Additionally, recent Census data suggest that the pandemic has only exacerbated housing instability among people of color.
These economic and housing impacts put Black, Latino/a, and other people of color at disproportionate risk of losing their health coverage at the end of the PHE. Changes in circumstances related to employment, income, and housing heighten the risk of individuals losing coverage as a result of churn. Medicaid agencies will face greater challenges in accessing the necessary income data to automate redetermination of eligibility for individuals with volatile employment situations, and will therefore be more reliant on sending paper notices requesting enrollee income information. Individuals who have experienced changes in employment face greater challenges in verifying their income. Additionally, Medicaid agencies will face challenges in locating enrollees who have moved or are newly experiencing homelessness to make them aware of redetermination requirements and request any necessary eligibility information.
Centering Equity in Planning for the End of the PHE
PHE unwinding and potential implications for coverage losses are a looming health equity issue. Accordingly, it will be critical for state and federal policymakers to take steps to ensure continuity of coverage and minimize disenrollment of Medicaid-eligible individuals following the end of the PHE and to ensure that redetermination efforts include an equity focus. States can deploy a variety of strategies to maximize coverage retention including:
- Launching a robust communications plan to leverage paid media, social media, consumer noticing, and partnership with community-based organizations to spread the word about upcoming Medicaid renewal requirements
- Engaging through a community-based approach with trusted messengers and community-based assisters to do outreach and assistance
- Leveraging managed care plans to engage in outreach and assistance activities through a community-based approach
- Collaborating with and funding navigators and assisters for outreach and renewal assistance
- Updating state IT systems to leverage the widest possible range of data to automate renewals
- Ensuring that paper forms are only used when required, and are simple, and pre-populated
- Employing a broad outreach strategy and opportunities to update address information
- To the extent they are found ineligible for Medicaid, ensuring that individuals are transferred to a state-based marketplace or Healthcare.gov for subsidized Marketplace coverage.
State Health and Value Strategies will be producing a variety of products and programming to support states as they plan for their PHE coverage transition. While the exact end date of the PHE is not currently known, what is known is that robust and immediate planning efforts by state and federal leaders are critical for ensuring that the end of the PHE does not exacerbate already widespread racial and ethnic disparities in the American health care system. At the same time, efforts to improve coverage retention post-PHE can have significant benefit on the broader public health by improving health care coverage and access for the population overall.
 FFCRA § 6008