The marked disruption that characterized the initial years of COVID-19, while distressing and destructive, also bore with it some radical implications. Jarred out of the course of our everyday lives, it seemed as if we might reexamine our assumptions and perhaps demand that the limited state assistance on offer continue, or even grow? So it had seemed, but those possibilities were soon foreclosed. Instead, the ruling class has touted a “return to normal,” as it hastens to unravel the few scraps of expanded social safety nets that were briefly extended to the people. Such a “normal,” of course, demands that we ignore the amassing long-term sufferers and the hundreds of continuing COVID-related deaths each week.
In keeping with this return to the neoliberal status quo, the expiration of pandemic protections means that, for the first time in three years, all U.S. states may now reevaluate — and terminate — their residents’ Medicaid enrollments. Some states have evidently been champing at the bit, leaping to cancel coverage for hundreds of thousands with incredible zeal. In fact, the review rate in certain states (predominantly red ones) has been so rapid that to date, the majority of their disenrollments have been “procedural” — i.e., due to clerical errors, miscommunications, unduly complex paperwork or other burdens of bureaucracy placed on individuals. The effect is to deny health care to eligible people on the grounds of what are essentially technicalities.
Some might call that scale of unnecessary dismissal an inexcusable system failure — especially because it carries very real ramifications for millions of people’s health, and indeed their lives. Regardless, procedural disenrollments have been ubiquitous throughout this process, cropping up in large numbers across the nationwide Medicaid review. Republican leadership in Arkansas and elsewhere have dictated an extreme pace while appearing curiously unbothered by the fact that their low-income residents are being severed from public health care in droves.
A Public Good, Briefly Glimpsed
For all its other stressors, the pandemic did at least spur the deployment of programs that offered U.S. residents some relief in crucial realms. The Families First Coronavirus Response Act (FFCRA), an emergency measure passed on March 18, 2020, notably specified a “continuous enrollment” condition. This stipulated that, for the duration of the official public health emergency, the removal of individuals from state Medicaid rolls would pause — whether those individuals remained eligible in the meantime or not. In return for enacting this policy, the FFCRA increased the federal medical funding that states received by 6.2 percent.
Health care in the U.S. is such that even this rather modest policy shift caused the rate of uninsured U.S. residents to fall “to the lowest level in its history,” per a press release from Democrats on the Energy & Commerce Committee. Between increased retention and new enrollments, the Medicaid rolls expanded by 23 million. (Analogously, the scattershot pandemic relief checks, which were not exactly extravagant giveaways, caused poverty to decline by 45 percent — also a record-breaker, this was the greatest drop in the shortest time in the nation’s existence.) These statistics indicate not the extraordinary generosity of the government during the crisis, but rather the desperate condition of so many U.S. citizens: such minimal assistance can drastically change their circumstances.
Procedural terminations constitute a full 73 percent of the total.
But the official end of the public health emergency has now been declared, accurately or not. As such, states are now poised to return not only to previous conditions, but to go further, reducing Medicaid enrollment to below its pre-COVID numbers — a “great reset,” you might call it. The brief experiment in decency now concluded, it is time to strip the unworthy of their ill-gotten care.
Kicked Off on a Technicality
The 2022 Consolidated Appropriations Act prepared the ground for the end of the FFCRA, funding the mechanisms necessary for states to resume “redeterminations” — in other words, deciding who to boot off the benefit rolls. Over the next 12 months, states are required to review all 93 million Medicaid enrollees for eligibility: a huge undertaking that is unheard of in Medicaid’s history. Only a few months into this process, 1.5 million have already lost coverage, per the Kaiser Family Foundation (KFF) tracker.
Information released by the Office of the Assistant Secretary for Planning and Evaluation’s (ASPE) Office of Health Policy projects that, in total, 15 million people, or 17.4 percent of all enrollees nationwide, are likely to lose Medicaid, whether because they’ve become officially ineligible since the FFCRA or for reasons of “administrative churn.” “Churn,” here, refers to procedural disenrollment — again, a loss of coverage not because a recipient has become ineligible, but due to clerical or logistical problems. This “churn” is projected to account for over 6.8 million removals.
Allie Gardner is a senior research associate at the Georgetown University McCourt School of Public Policy’s Center for Children and Families. As she described to Truthout, “Our biggest concern going into the [FFCRA] unwinding has come true: people are being disenrolled not because they’re being found ineligible for coverage, but because they’re being caught in red-tape barriers.”
The proverbial red tape has already tied down coverage for Amy Lindsey, an Arkansas resident who is contending with precarious circumstances as she raises her 5-month-old. “It’s been difficult and stressful,” she told Truthout. “I’m living on a pretty low income right now. I’m a single mom, and I’m working two jobs. And I don’t have the benefits that I used to, like food stamps.” And now, her Medicaid coverage.
Lindsey had been on Medicaid for over a year before the pandemic. But when Arkansas’s redetermination process began, she found she’d been unceremoniously disenrolled. Advocating for her case was a months-long challenge and a logistical nightmare: “They were telling me that they were never able to make contact with me. They said that they sent me mail, sent me documents, sent me letters, telling me that my [coverage] would get taken away if I didn’t bring in the proper things.”
Even attempting to find guidance can be daunting. Mail can be slow and unreliable, and phone lines are often snarled: “I went into the DHS [Department of Human Services] office because you can’t ever really get through when you’re calling them,” said Lindsey. “I’ve called 20 to 50 times in a day, sometimes.”
“So, you have to go down to the office, and their operating hours are pretty much aligned with my working hours. So that takes away from my pay as well, and time with my son.” For working people, these demands can be simply impractical.
“Right when I received the information that my case was going to be closed, I ended up getting incredibly sick, very, very sick. None of the local health clinics, even the walk-ins, would see me.”
Gardner added, “The renewal process is very complicated, and some of the documentation and the actions required to remain eligible are not clear in the notices [Medicaid recipients] receive.”
In fact, the instructions can be outright misleading: according to Gardner, a number of states told enrollees words to the effect that “‘If you get a notice from the state, you don’t need to worry about it. Toss it, don’t pay attention to it.’ There has not been a clear messaging shift,” she added, “[around the fact that] notices are now important and are required to maintain Medicaid eligibility.”
Procedural Disaster
Such maddening states of affairs are not uncommon. In fact, they currently seem to be more common than not: Statistics assembled by the KFF, which is tracking the ongoing Medicaid review across all states with available data, indicate that as of late June, procedural terminations constitute a full 73 percent of the total. In some states, per the KFF, procedural disenrollment rates are presently exceeding 95 percent.
Over time, this will decrease; these statistics are frontloaded due to the ordering of the purges, and ASPE estimates that the final procedural disenrollment rates will reach 30 percent. There’s also a caveat to note: it’s likely that some of those removed for procedural reasons may also have become ineligible and would have been dropped anyway.
Still, as the KFF also found, “[N]early two-thirds of current Medicaid enrollees said they did not have a change in income or circumstance in the past year that would make them ineligible for Medicaid.” On the whole, “the survey findings suggest many of the people whose coverage was terminated for procedural reasons in the past month likely remain eligible.”
Even if the rate settles to the predicted 30 percent, it will still be a startling figure. We might wonder how so many errors could possibly occur in the basic mechanisms of such a venerated program, especially one that dates back 60 years.
Eager Efficiency
“While all states are removing people from their Medicaid rolls,” pointed out Megan Messerly in an article for Politico, “several Republican-led states appear to be moving at breakneck speed and no state is moving as quickly as Arkansas.” The unusual promptness and efficiency of this service is thanks to the administration of one-time Trump flack and current Governor of Arkansas Sarah Huckabee Sanders.
Sanders announced in a gubernatorial op-ed in The Wall Street Journal that the state’s intent is to complete all “redeterminations” for eligibility within six months, rather than the recommended yearlong timeline. Critics and federal officials say it will be impossible to properly and fairly review all recipients in that limited time frame.
“States like Arkansas now have a legislative mandate to go through the unwinding process faster,” Gardner pointed out to Truthout. A number of states (like Florida and Arizona, currently in the disenrollment lead ahead of Arkansas) are also in a hurry to burn through the process as fast as possible — in a way that is certain to generate errors and mistakes, guaranteeing policy cancellations that could have been avoided.
Any imputation of specific motives onto a given state government would be conjectural. But it is worth bearing in mind that, in the course of the century-long war against U.S. social assistance programs, when de jure measures have not been available to slash the rolls — whether of welfare recipients or voter registrations — the opponents of state aid have not hesitated to turn to disenrollment de facto.
In the postbellum Reconstruction-era South, rigged literacy tests were infamously mandated to disenfranchise Black voters. Modern right-wing voter suppression tactics are not much different. Examples include requiring ID or other documentation at the polls, creating inconvenient schedules and byzantine rules, and, in Georgia, going so far as to make it “a crime to provide food and water to voters standing in line at the polls — lines that are notoriously long in Georgia, especially for communities of color,” as the ACLU pointed out.
The neoliberal state of “normalcy” means that, in the absence of popular resistance, the ownership class shall give and take away as it pleases.
In welfare programs, indirect structural factors can produce comparable effects: dictating the means-testing (i.e., income targeting) of programs instead of making them universally available, for instance, necessitates burdensome bureaucracy to evaluate prospective enrollees for work or income strictures. These obstacles might have their origins in mechanisms intended to delimit programs to the sole use of those in need — or, more maliciously, they might be deployed intentionally to exclude certain demographics. To the advantage of welfare opponents, the result of imposing such technicalities is to disconnect people from social programs, effectively cutting programs without wading into a legislative battle.
Back to Normalcy
For Medicaid recipients, who already face socioeconomic challenges, these machinations only mean multiplying hardships. If enrollees are disabled or mentally ill, the paperwork demands can become insurmountable entirely.
In Amy Lindsey’s case, months of confusion still lay ahead in her efforts to regain her health care. During her dealings with the state office, constant complications ensued: wrong members of the household listed, updates received at the wrong phone number, documents that disappeared in the mail.
At her lowest point, things became desperate. “Right when I received the information that my case was going to be closed, I ended up getting incredibly sick, very, very sick. None of the local health clinics, even the walk-ins, would see me … I was fearful I would be out of work even longer.”
A solution of sorts may have been reached, as Lindsey appears to have been shunted over to a state coverage plan, though the details are still unclear — much in the way that coverage status for so many others remains baffling and opaque. “It’s been so frustrating, and I’ve been so overwhelmed that I haven’t even looked into any of that yet. I just threw my hands up.” It’s hard to blame her.
Unfortunately, the slashing of the rolls by states like Florida and Arkansas might portend comparable losses of benefits across the country. Caught at this junction of underfunded, inefficient bureaucracy and the ongoing sabotage of social services (another episode in its very long and very bipartisan history), innumerable people in need will go untreated. In a wider view, it should also be taken into account that up to 7.4 million uninsured non-elderly people are eligible for Medicaid — and yet have never signed up. Six in ten of those 7.4 million are people of color; fully one-third are children.
Evidently, as parallel late-pandemic battles like that over student loan relief have also made clear, it was too much to hope that the marginal social aid on offer during the pandemic might represent anything more than a whim of the state, hesitantly given and promptly retracted. The neoliberal state of “normalcy” means that, in the absence of popular resistance, the ownership class shall give and take away as it pleases. It seems we have indeed returned to such a status quo, just as our elite leadership so vocally demanded. It is the social realities and the moral character of that status quo that are in question.