On March 13, 2020, as it became clear to more and more Americans that the threat from the pandemic would be serious, President Donald Trump declared a national emergency, which then enabled his secretary of Health and Human Services, Alex Azar, to declare a public health emergency (PHE). That declaration gave the federal government expanded powers and flexibility to ensure that people got the care they needed by temporarily waiving or modifying “certain requirements of the Medicare, Medicaid and State Children’s Health Insurance programs and of the Health Insurance Portability and Accountability Act Privacy Rule.” The Department of Health and Human Services then told the states to stop their annual assessments of whether people still qualified for public healthcare and instead just let everyone keep their Medicaid (and related programs) until the emergency was over.
The move worked. Over 82 million Americans now receive healthcare via Medicaid and the Children’s Health Insurance Program, up from 71 million before the pandemic. And their access to care has been kept secure by the emergency measures. “Continuous enrollment,” or the pausing of all the usual mechanisms by which people are booted off public health systems, ended the problem of “churn.” Prior to the pandemic, every year, people left Medicaid. Some did have changes in economic circumstances that made them ineligible and, ideally, helped them climb out of poverty. But up to 50 percent of the people who left rejoined within a few months. Many of those who didn’t rejoin would still have been eligible. In some cases, individuals and families bounce back and forth across the eligibility line due to short-term changes in employment and expenses, but often it’s just about the paperwork: They don’t get the forms, don’t return them or don’t fill them out correctly. Loss of coverage has dire health consequences for individuals and comes with costs for the state. The public health emergency “continuous enrollment” policy has solved many long-standing problems with who gets and who keeps Medicaid.
But the “emergency” seems likely to end soon — at least, that’s the expectation among state health officials who are preparing for the next phase and public health activists and academics working on Medicaid and disability policy. What’s more, more than 70 House Republicans recently called for President Joe Biden to present a plan for ending the emergency by March 15. A number of former Biden public health advisers are proposing rethinking the approach to mitigating the virus, and current Biden officials are increasingly discussing returning to pre-pandemic policies (or what they call “normal”). The status quo seems unlikely to last. So what happens to Medicaid?
“It’s going to be a sh*tshow,” Pamela Herd wrote to Grid over Messenger, when asked about what’s coming next. Herd is a professor of public policy at Georgetown University and co-author of a book on “administrative burdens,” the systems that can (often intentionally in Herd’s analysis) block people’s access to vital programs and perpetuate inequalities. “Even in normal times,” she later said over the phone, “when people know this is coming, a lot of people lose coverage who should not be losing coverage,” often just because the state doesn’t have up-to-date mailing addresses. “Low-income populations have to move around a lot. They get evicted. Their lease cost goes up,” she added.
As a result, it’s common for states to have trouble locating people, a problem that’s going to be intensified with the multiyear pause in the recertification process. Moreover, anyone who is new to Medicaid has never been through this process and might well not know it’s coming. “I don’t think there’s any way to prevent damage; a lot of people are going to lose coverage who shouldn’t,” Herd said. But states might be able to maximize the flexibility and generosity they show to people as the emergency ends. Herd said that states should not remove people from Medicaid rolls simply because of an unreturned form, should collaborate with other initiatives like SNAP (food assistance) that often have more recently updated addresses for those who use their services, and could perhaps work with tax agencies. She said, “Maximize whatever administrative capacity you have.”
Generosity in particular is going to be important, because whatever happens to the pandemic, the health outcomes for the nation as a whole are looking much worse over the long term. Maria Town, CEO of the American Association of People with Disabilities, said that her organization has asked the Biden administration to prepare an executive order focused on how agencies — including the Centers for Medicare and Medicaid Services (CMS) as well as Social Security, the Occupational Safety and Health Administration (OSHA), etc. — will manage the increased need for robust public health systems created by “long covid.” Post-covid conditions are increasingly associated with long-term health consequences, such as a heightened risk for potentially lethal cardiovascular problems, leading to a rapidly swelling population of disabled Americans.
In fact, Town said, “Disabilities of all sorts have worsened due to a lack of healthcare” during the pandemic, including, she pointed out, conditions stemming from more advanced cancers because people avoided seeking screenings. All of this leads to more people needing more healthcare. Town wants the Biden administration to push states to look at everyone who joined the program during the emergency before they start the re-certifications and “just keep them on the program [if they are eligible]. Why force someone to re-apply?” Town and other experts are worried that people who are new to Medicaid and have never been through the re-approval process are particularly likely to make mistakes, get caught up in the chaos and lose their benefits.
Medicaid is administered through state governments, which have a lot of leeway in the choices they make. And as state political leanings differ, so naturally does support for a more expansive or restrictive administration of public health benefits. But most of the money for Medicaid (in a complex formula) comes from the federal government, which gives the Biden administration considerable power over what happens when the public health emergency ends. Experts seem to agree that while CMS might urge flexibility and provide resources for states that desired them, it’s less clear what specifically CMS can mandate.
Political support for Medicaid, of course, varies widely. Republicans started trying to cap Medicaid expenditures under President Ronald Reagan, most recently as part of their failed attempt to overturn the Affordable Care Act. Most of the American Southeast, Texas and a handful of other states refused to expand Medicaid under the ACA. (In some states, voters managed to overrule their elected leaders and adopt the expansion via ballot initiative.) So the response to the ending of the emergency in Minnesota, where I live, will likely be very different than in neighboring South Dakota.
Bethany Lilly, director of income policy at the Arc, said that CMS can pressure states to, for example, structure the process of determining who stays on Medicaid by prioritizing the most vulnerable. There are far too many people receiving Medicaid services to assess everyone’s eligibility all at once, so “[states could] put children with disabilities toward the end of the list. CMS should be pressuring states to do it.” In other words, if someone is a senior or a disabled child, assess their eligibility last. But it’s still up to the states, and Lilly doesn’t think CMS can force states to work in this common-sense way (though most are doing so, she told Grid). “It’s a partnership. [CMS has] the power of the purse, but legally there’s limits of what they can force states to do.”
Lilly is deeply concerned about the phone and mail backlogs, with vast numbers of messages in all formats going unanswered, leading to people losing access to all kinds of governmental supports once the emergency ends. What’s more, although CMS has been putting out guidance, she thinks it is underestimating the fear factor. “CMS is kinda missing the boat. This is gonna be terrifying for every single person, family, individual,” who hears from the government: “We have eligibility questions.” Right now, it’s all too technical: “The list of guidances is 200 pages long,” she said.
Matthew Cortland, senior fellow at Data for Progress, said that one thing CMS definitely controls is the length of time that states have to process. “They can say … we will give you a year to process the disentitlement paperwork. Could they make that two years? I believe so.” Cortland said that CMS can offer states more time to sort out the post-emergency situation, and many states will use that latitude, but not all state governments are equally committed to providing healthcare to those in need. In what he characterizes as “bad actor” states, where antipathy to Medicaid runs high, there’s less that CMS can do. “CMS can say, ‘We’ll give up to one year,’ but that doesn’t mean states have to take one year.” Once the public health emergency ends, a state can move very quickly to shrink its rolls. But what if the emergency didn’t end? “The legal mechanism to protect those people,” he said, “is to extend the public health emergency.”
Lilly agreed, saying, “They could just continue to extend the PHE as people figure this out. They don’t have to end it.”
My son is a 15-year-old autistic boy with Down syndrome. He receives Medicaid-related services from the state of Minnesota, which is known for its comparatively robust social services network. In fact, we moved here from Illinois in order to live in a state that we felt was likely to provide him a higher quality of support when he becomes an adult. Everyone we’ve encountered has been well-intentioned, and resources are plentiful. But it took years to figure out what he actually qualified for; the paperwork piles up on a monthly basis; and we often miss out on supports we could have gotten. Right now, on my kitchen table is a long form asking for details about my private healthcare and my son’s needs, all of which I filled out last year — but there’s no “unchanged” box to check.
The public health emergency has shown us how access to systems like Medicaid is hindered by bureaucratic obstacles that are superfluous to the functioning of the system. In fact, they are often counterproductive, leading people to lose care to which they are entitled and weakening the social safety net. The success of the PHE declaration in expanding access to Medicaid shows that the Biden administration has the power to minimize needless hurdles between Americans and the services designed to keep them safer and healthier.