Medicaid “Unwinding” Is Largest Loss of Health Coverage in US History

After the uninsured rate fell to an all-time low of 8 percent in 2022, nearly 6.8 million people have lost their Medicaid health coverage since the so-called unwinding of federal pandemic protections began earlier this year. Observers say it’s the largest simultaneous loss of health coverage in United States history, with impacts threatening to reverberate through the already struggling health care system for years.

Millions of people are losing Medicaid coverage after failing to reapply or file paperwork with state agencies, not the federal government, but some say the massive loss of health insurance still threatens to tarnish the legacy of President Joe Biden. Financed by the federal government but run by the states, Medicaid provides health coverage for millions of children, elderly and disabled people as well as lower-income workers in highly profitable industries.

“It’s the largest simultaneous disenrollment in American history.… This is going to become the health care legacy of the Biden presidency,” said Beatrice Alder Bolton, co-host of the “Death Panel” podcast and author of Health Communism: A Surplus Manifesto, in a recent statement to reporters. “This doesn’t reflect what Biden is projecting as his vision of healthcare in America.”

The president pledged on the campaign trail to expand eligibility for Medicaid to people in mostly southern states where conservatives have refused to expand the program under the Affordable Care Act (ACA), and his administration has worked to expand health care coverage and strengthen the ACA.

In 2014 alone, the ACA’s expansion of Medicaid enrollment brought 13 million people into the program, according to Boston. Currently, Medicaid disenrollment is set to continue in state-by-state waves until the spring of 2024, and a similar number of adults and children — Boston estimates about 10 million — could lose coverage over the course of a year-long “unwinding” period, which began with the expiration of emergency pandemic enrollment protections on March 31.

The Kaiser Family Foundation, which is tracking Medicaid disenrollment in 48 states, estimates that between 8 million and 24 million adults and children will lose their Medicaid coverage by 2024. At least 6,767,000 Medicaid enrollees have lost coverage as of September 19, although researchers say that number is likely an undercount.

Meanwhile, House Republicans are targeting Medicaid and other safety net programs for steep cuts as GOP leadership wrangles with far right lawmakers over a budget deal needed to avoid a government shutdown. The White House said this week that Biden and Senate Democrats would oppose the roughly $9 trillion in proposed cuts to “mandatory spending” programs such as Medicare, Social Security and food stamps laid out in a Republican budget blueprint this week, including nearly $2 trillion in cuts to Medicaid.

Beginning in 2020 as COVID-19 swept the nation, Congress temporarily expanded access to Medicaid and a “continuous coverage protection” prevented states from booting people from the program during a global pandemic. This eliminated what’s known as “churn,” in which eligible enrollees lose coverage on their renewal date and have to reapply for health insurance, typically with a state agency that administers Medicaid.

Nationally, participation in Medicaid swelled by 30 percent during the COVID-19 public health crisis. Along with enhancement to ACA Marketplace insurance programs, the pandemic-era health protections pushed down the national uninsured rate from 9.2 percent in 2019 to an all-time low of 8 percent in 2022, according to the Center for Budget and Policy Priorities.

But the pandemic-era protections no longer apply, and states are taking radically different approaches to updating their Medicaid rolls and purging people who are no longer eligible or fall victim to churn and fail to return renewal applications on time. For example, Michigan has so far reported Medicaid disenrollment at 9 percent while Texas is reporting that 69 percent of enrollees are losing coverage, according to the Kaiser tracker.

Overall, 72 percent of all people disenrolled so far have lost their coverage for procedural reasons, such as failing to apply for renewal on time, which can happen when state agencies have outdated contact information for enrollees. Many of these people were simply unable to put their paperwork together on time, if they knew about renewal requirements in the first place.

Courts and policy makers are attempting to mitigate the damage in some states. In Nevada, which initially had one of the highest rates of procedural disenrollment rates in the nation, about 114,000 Medicaid enrollees will have their coverage reinstated by the state Medicaid agency, according to the Nevada Current.

Medicaid ”unwinding” has taken a heavy toll on enrollees living with disabilities or living in rural areas, especially those who do not have regular access to internet services or those who have recently changed their addresses. In many parts of the country, disenrollment has a “domino effect” that puts additional pressure on food pantries and other safety net services both public and private. States have invested various amounts of money in their capacity to warn enrollees about upcoming deadlines and renewal dates, with states such as Texas and South Carolina targeting enrollees auditors suspect are no longer eligible.

Bolton said the federal Centers for Medicare & Medicaid Services (CMS) has the authority to halt disenrollment for procedural reasons such as paperwork, and called on the Biden administration to step in as states such as Texas, Idaho, Wisconsin and Montana report Medicaid disenrollment rates at or above 60 percent.

“We’re only a few months into this and 74 percent are procedural determinations,” Boston said. “CMS should be saying pause.… It’s their responsibility to do it.”