off the charts
POLICY INSIGHT
BEYOND THE NUMBERS

Congress Can Help Prevent Health Coverage Disruptions, Lock in Recent Gains

The uninsured rate is at a record low, according to the latest Census data. One major reason: the temporary prohibition on terminating Medicaid coverage for most enrollees during the federally declared public health emergency (PHE). But this “continuous coverage” requirement will phase out when the PHE ends, likely next year. As Congress begins work on end-of-year legislation, policies that protect and bolster health coverage, particularly for low-income people, should be a top priority.

Medicaid’s continuous coverage provision has helped keep people, including millions of children, insured despite the economic and social disruption caused by the COVID-19 pandemic. The continuous coverage requirement helped prevent the churn on and off Medicaid coverage that often happens as people’s income fluctuates, or if they can’t meet paperwork requirements that are often part of eligibility checks. Churn harms Medicaid enrollees, disrupting their access to medications and other needed care, and it’s also administratively burdensome for states, providers, and health plans. Research also shows that paperwork requirements and other administrative burdens often mean that people lose coverage and do not reenroll in Medicaid or other programs they might be eligible for.

Congress should learn important lessons from the last two years and enact policies to help minimize coverage disruptions when the continuous coverage requirement ends. Doing so now could help stem widely anticipated coverage losses and secure widespread coverage for the future, giving more people access to life-saving health care and financial protection. Enacting policies to help retain record low uninsured levels is also key to advancing health equity; the uninsured rate fell to a record low among Black people in 2021. Policymakers should prioritize approaches to maintain these gains.

Congress should include the following policies in year-end legislation to minimize coverage disruptions and loss of coverage, and to help lock in coverage gains:

  • Extend postpartum coverage to 12 months. Recognizing the importance of uninterrupted coverage after giving birth, the American Rescue Plan gave states the option to extend postpartum coverage for 12 months after childbirth, rather than the 60 days otherwise required by law. To date, 33 states and the District of Columbia have taken up the option or have announced plans to do so. But the American Rescue Plan coverage option is available only through March 2027.

    To help reduce the maternal and infant mortality crisis, Congress should permanently increase mandatory pregnancy coverage from 60 days to one year postpartum. Doing so could eliminate the risk of coverage disruptions in all states, but it’s particularly important in the 12 states that have not expanded Medicaid, as postpartum people with very low incomes often lose Medicaid coverage 60 days after giving birth in non-expansion states. Requiring a full year of postpartum coverage in all states could help address maternal health equity; postpartum coverage is especially important for Black people, who are somewhat likelier to experience life-threatening pregnancy complications in the late postpartum period (between six weeks and one year after childbirth) than white people.

  • Require continuous eligibility for children. Even before the PHE continuous coverage requirement, states had the option to provide “continuous eligibility” to children, meaning that children remain eligible for Medicaid (or the Children’s Health Insurance Program, or CHIP) for a 12-month period regardless of changes in their family’s income. As of January 2022, some 32 states (including D.C.) provided 12 months of continuous eligibility for children under 19 in Medicaid and/or CHIP.

    Providing continuous coverage for children increases the share of children accessing preventive care, and reduces the shares experiencing gaps in coverage and with unmet medical needs, research shows. It also reduces administrative burden and administrative costs for states. The evidence is strong, and Congress should require all states to implement continuous eligibility for children. Doing so would help advance health equity by promoting continuity of coverage for children from families with low incomes, who experience disproportionate rates of health disparities.

  • Introduce at least a state plan option for continuous eligibility for adults. Continuous 12-month eligibility can help prevent coverage losses among adults, too, and could further help children since adult enrollment is positively correlated with children’s enrollment. At a minimum, Congress should permit — if not require — states to provide 12 months continuous eligibility to adults without seeking federal approval through a Section 1115 demonstration, or waiver. As of earlier this year, four states had used Section 1115 demonstration projects to authorize continuous eligibility for adults. Last week, two more states — Massachusetts and Oregon — received approval to provide continuous eligibility to some or all adults (along with groundbreaking continuous eligibility for kids through age 5 in Oregon). Even if Congress doesn’t require it, more states would adopt this important policy if Congress gives states a permanent state plan option to adopt continuous coverage for adults.
  • Provide additional funding for Puerto Rico and the other U.S. Territories. Without congressional action this year, more than 1 million residents in Puerto Rico who rely on Medicaid for their health care could face deep cuts to eligibility, benefits, and already low provider payments. As in the states, the uninsured rate in Puerto Rico dropped between 2019 and 2021, from 7.8 percent to 5.7 percent. At least some of this drop is due to the continuous coverage requirement and to increased Medicaid funding provided during the last several years. Given the unique funding challenges in the territories, providing Puerto Rico and other territories with the funding they need to avoid cutting eligibility is critical to maintaining coverage; that’s particularly true for Puerto Rico to help prevent people from losing coverage as residents recover from the destruction and dislocation caused by Hurricane Fiona.

Congress can help maintain recent health coverage gains through enacting policies including postpartum coverage, continuous eligibility, and funding for Puerto Rico and the territories. As policymakers negotiate the year-end spending bill, they should also consider other policies — such as a permanent reauthorization of CHIP and inclusion of the proposed Medicaid Reentry Act — that also could help people with low incomes gain, retain, or access the coverage they need.