Lessons Learned From Unwinding Can Improve Medicaid

As 2024 kicks off and the unwinding of Medicaid’s continuous coverage requirement reaches its halfway point, it’s clearer than ever that administrative burdens are leading eligible people to lose coverage. At least 15 million people have lost Medicaid, and nationwide about 71 percent were disenrolled for procedural reasons. That means they lost coverage because they didn’t complete a step in the renewal process, not because they were actually determined to be ineligible. As we discussed in a recent Health Affairs article, unwinding should be a call to action to fix a fragmented Medicaid system that often fails to serve our most vulnerable.

While it is not too late to improve the unwinding process, we must also look ahead to permanently fixing inefficiencies in Medicaid applications and renewals. These inefficiencies are burdening enrollees and eligibility workers and resulting in incorrect denials and terminations of coverage.

A first step would be to make sure states follow the law. The unwinding process has exposed many instances where states fall short of long-standing federal requirements. We’ve learned that:

• Some states don’t let enrollees submit renewals online or by phone.
• Others don’t properly screen enrollees for all categories of coverage for which they might be eligible.
• Many states still don’t meet the requirement to attempt an ex parte renewal, which uses data sources to confirm eligibility without requiring an enrollee to fill out a form.

Even when states meet the technical letter of the law, some do so ineffectively:

• Online renewals may be poorly designed and require burdensome identity proofing.
• Call centers may be poorly staffed, leaving callers to face hours-long wait times.
• Some ex parte processes are overly restrictive, which means hardly anyone’s renewal gets completed automatically in those states.

These inefficiencies can have serious health consequences. People who incorrectly lose Medicaid may believe they’re no longer eligible and remain uninsured. Others may reapply but experience a gap in coverage that leads them to delay getting care or go without needed medications.

The “churn” of individuals on and off Medicaid bogs down already understaffed agencies. States have seen a substantial increase in applications since unwinding began, including re-applications from people who recently lost coverage. Many are experiencing major delays, with more than a quarter of applications processed beyond the allowable timeframe.

The news isn’t all bad. Some states have invested in innovative approaches to serve people better during unwinding. For example:

• More states are communicating via text message.
• Most states are making use of various data sources to maintain updated contact information for enrollees.
• Most agencies are investing resources in systems and policy updates to improve their ex parte processes, demonstrating that high rates of automated renewals are possible.

The Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid, has also stepped up in the unwinding process with an unprecedented level of engagement, scrutiny, and technical assistance to states. This has led states to implement mitigation strategies while they fix their systems, pause procedural terminations while they address issues, and develop a clearer understanding of federal policy and expectations as they work to comply with federal law.

We need the unprecedented data transparency from both states and CMS over the last year to endure so we can continue to monitor progress. And we need CMS to finish the job and bring states into compliance with the law as quickly as possible. To make that happen, CMS should delineate clear next steps for each state — including concrete timelines — and make the plans public so advocates can help hold states accountable. To support this work, Congress should ensure that CMS has the resources it needs to continue its extensive work with states and to robustly oversee state compliance with Medicaid laws now and in the future.

Unwinding has shown that progress is possible when states are innovative, and federal agencies are involved and push states to do better. But this period has also revealed how much hassle and hardship low-income families must endure to secure benefits to which they are entitled.

We can — and must — do better.