Data Note
April 2024
Peter Shin, Sara Rosenbaum, Rebecca Morris, Feygele Jacobs
On April 1, 2023, states began the largest planned Medicaid enrollment reduction ever undertaken. Medicaid unwinding.1 By the end of March 2023, Medicaid enrollment had grown nationally to 94 million people,2 reflecting the impact of continuous enrollment on the problem of Medicaid churn, which happens when beneficiaries bump up against the program’s strict eligibility rules.3 For three years, continuous enrollment paused churn; the unwinding process effectively reinstated it.
Experts anticipated that reinstating the normal eligibility review process would lead to widespread coverage losses; they estimated that about 15 million children and adults would lose coverage, about half for purely procedural reasons unrelated to an actual finding of ineligibility.4 But by March 2024, even with several months remaining to the unwinding completion date, Medicaid disenrollments had surpassed 19.2 million beneficiaries including 4.76 million children.5 Moreover, procedural disenrollments now account for 70 percent of all disenrollments, especially in states in which the streamlined ex parte renewal system instituted by the Affordable Care Act failed to function.6
The high disenrollment rates are likely influenced by the failure on the part of some states to adopt a range of administrative flexibilities allowed during unwinding that simplify and streamline the redetermination process7
and states’ underlying highly restrictive Medicaid eligibility rules that leave a far higher proportion of beneficiaries without a pathway to continued coverage. For example, in the 10 states that have rejected the Medicaid expansion, children reaching 18 and women who have reached the end of their postpartum eligibility period likely have no basis for continued eligibility because of their state’s decision not to insure all working age adults with incomes up to 138 percent of the federal poverty level. Additionally, many states have failed to evaluate each beneficiary and instead have reviewed families as a single unit, which has led to the erroneous termination of many children, whose eligibility levels are often significantly higher than financial eligibility levels for parents.8
Community health centers (CHCs)9
can provide important insight into how unwinding may be affecting both coverage and care, not only because they provide care to approximately one in six Medicaid beneficiaries nationwide but because they serve patients regardless of insurance status and thus remain a source of comprehensive primary care even when patients lose their insurance coverage.
CHCs can be expected to experience two important effects. First, thousands of patients will lose Medicaid coverage, and with the loss they will also lose their health plan memberships and the access to specialty provider networks that health center staff depend on to be able to manage care for patients in need of specialty services outside the health center. Second, as the proportion of insured patients falls, CHCs will experience a revenue decline that cannot be offset by grants, which, despite their importance, comprise less than 20 percent of CHC operating revenue. News reports have begun to document these effects,10
as has a study of Medicaid enrollment declines among CHC patients as unwinding proceeds.11
This Study
This study goes behind the impact data to more deeply understand how Medicaid loss is affecting health centers and their patients. To conduct this analysis, the National Association of Community Health Centers (NACHC) and George Washington University’s Geiger Gibson Program in Community Health jointly surveyed CHCs over four weeks between January and February 2024. Of 1,487 CHCs nationwide, including 117 look-alike health centers which do not receive federal health center grants, 222 CHCs (15%) responded to the survey. The brief survey asked seven questions about the impact of the unwinding on CHC revenue, operations, and patient care, as well as state engagement and CHC redetermination activities.12 The findings provide insight on how the unwinding is impacting a major group of safety-net primary care providers and their patients.• Health centers and patients nationwide are being affected and the impact is sizable. Nearly 95 percent of CHCs reported that patients have been disenrolled, and among those reporting disenrollment, an estimated 23% (nearly 1 in 4 patients) have been disenrolled (Figure 1). This figure is slightly higher than the Medicaid disenrollments of 20% reported as of March 2024, and within the range of up to 28% estimated in recent projections.13
• Few disenrolled patients have been successfully reenrolled. Among patients who have been disenrolled, an estimated 26% (slightly more than 1 in 4) have been successfully reenrolled. Three quarters of disenrolled patients remain disenrolled (Figure 2).
• Disenrollment is affecting patients across the lifespan and disrupting care. CHCs report that disenrollment has affected patients across all ages including those with major health needs, with two-thirds of those disenrolled (63%) also experiencing significant disruptions in care. Nearly half (49%) reported that patients lost access to managed care specialty, hospital, or other care needed outside the health center, while half reported that patients had missed their scheduled appointments, or that patients had discontinued or postponed ongoing treatment (Figure 3).
Nearly one-third (32%) of patients who were disenrolled were patients of all ages with disabilities, a group in particular need of specialized health services falling outside the capabilities of many health centers.14 Additionally, an estimated 12 % of those disenrolled were patients with chronic conditions, while 12% were older adults over the age of 65, and nearly one quarter (24%) of disenrolled patients were children (Figure 4).
- Disenrollment from Medicaid and the risk of disruption of care for children has been particularly pronounced in Medicaid ACA non-expansion states. In ACA non-expansion states, health centers report that 40 percent of disenrolled patients were children – two in five disenrolled patients - compared to 20 percent in Medicaid expansion states that insure all low-income working-age adults (Figure 5). The reasons for this are unclear; one possibility is that far more adults in non-expansion states presumably had no continuing coverage pathway once continuous coverage ended, meaning that far more children would have been affected where states failed to separately and independently review children’s eligibility. Thus, for example, a child living with a parent in Texas, where the income eligibility for parents is 16% of the federal poverty level, would have faced a far greater probability of coverage loss if redeterminations were at the family level than those living in states covering all low-income working age adults with incomes up to 138% of the federal poverty level. Complicating matters further, children living in exceptionally poor families may be in greater need of specialized care for physical, mental, and developmental conditions compared to their less impoverished counterparts, and require services often available only by referral outside the primary care setting.
- Navigating the renewal process poses significant problems. Consistent with other reports on the difficulties of navigating renewals, CHCs reported a wide range of problems encountered by their patients. Nearly all CHCs reported that patients had significant difficulty with the Medicaid redetermination process and either were not notified or else failed to understand the process, the actions that might be required of them, or how to respond to the coverage renewal process; significantly, 85% (189) reported that patients did not understand the renewal notice. Nearly two thirds (62%) reported that patients failed to receive a renewal notice, nearly 70% reported that patients experienced general difficulty navigating the state website, two thirds reported that patients had to make multiple attempts to renew coverage, more than half reported that patients could not connect to a call center, over two in five reported that patients could not log into the state portal, and nearly one third of all CHC respondents reported that patients received incorrect or conflicting information from the call center (Figure 6).
- Virtually all CHCs are actively engaged in the redetermination effort, while three quarters report working with their states to mitigate coverage loss. Seventy-three percent of respondents report engaging with their state agencies to support the redetermination process, and working to update and correct patient information and identify necessary changes to ease the process. Virtually all respondents report actively conducting outreach and education, assisting patients with updating needed documents, coordinating with community-based organizations, and helping those losing coverage find and enroll in other insurance, such as marketplace health plans (Figure 7).
This analysis confirms that consistent with the nationwide unwinding process, patient disenrollment is experienced by virtually all community health centers. An estimated one in four health center patients has lost coverage to date, including high numbers of children, and most who experience disenrollment remain disenrolled. Care disruption is considerable for disenrolled patients and perhaps most strikingly for disabled individuals, those with chronic conditions, and children, who constitute 40% of disenrolled CHC patients in states that have not adopted the ACA expansion. This analysis also underscores health centers’ active efforts to stem both procedural and erroneous disenrollments and to actively engage with their state agencies to mitigate unwinding problems as they become evident.
If these coverage loss estimates (disenrollment of 1 in 4 health center patients) remain consistent as unwinding continues into 2024, CHCs can expect that more than 3.5 million patients will experience coverage disruptions.15
Similarly, if the low reenrollment rate seen here remains constant, then three-fourths of all patients losing Medicaid will remain disenrolled, leading to disruption not only in coverage but in care itself, along with substantial revenue loss that will further affect ongoing CHC operations. Most concerning, perhaps, is disruption in pediatric coverage as well as care for the highest-need patients including those with chronic conditions or disabilities. This suggests that going forward, there is an enormous need for especially intensive focus on these particular populations by states and health centers alike.
- CMS (2024). Unwinding and Returning to Regular Operations after COVID-19. Accessed April 1, 2024 at https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-…↩
- KFF (2024). Medicaid Enrollment and Unwinding Tracker. Accessed April 1, 2024 at https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tr….↩
- Wikle, S. (2024). Medicaid Unwinding Leads to Churn, Backlogs, and Delayed Services in Many States. CLASP. accessed April 1, 2024 at https://www.clasp.org/blog/medicaid-unwinding-leads-to-churn-backlogs-a….↩
- ASPE (2022).Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches* Accessed April, 1, 2024 at https://aspe.hhs.gov/sites/default/files/documents/dc73e82abf7fc26b6a8e…;↩
- Center for Children and Families (2024). How many children are losing Medicaid? Georgetown University. Accessed April 1, 2024 at https://ccf.georgetown.edu/2023/09/27/how-many-children-are-losing-medi…↩
- Rosenbaum, S. (2024). When Medicaid Unwinding Meets AI: In the Matter of DeLoitte Consulting. The Milbank Quarterly. Accessed April 1, 2024 at https://www.milbank.org/quarterly/opinions/when-medicaid-unwinding-meet….↩
- CMS (2024). COVID-19 PHE Unwinding Section 1902(e)(14)(A) Waiver Approvals. Accessed April 1, 2024 at https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-…;↩
- CMS (2023). Coverage for Half a Million Children and Families Will Be Reinstated Thanks to HHS’ Swift Action. Accessed April 1, 2024 at https://www.cms.gov/newsroom/press-releases/coverage-half-million-child….↩
- HRSA (n.d.). What is a Health Center? Accessed April 1, 2024 at https://bphc.hrsa.gov/about-health-center-program/what-health-center.&n…;↩
- Weiland, N. (2024). As Medicaid Shrinks Clinics for the Poor are Trying to Survive. New York Times. Accessed April 1, 2024 at https://www.nytimes.com/2024/02/24/health/medicaid-loss-clinics.html↩
- Bensken, W. P., Koroukian, S. M., McGrath, B. M., Alberti, P. M., Cottrell, E. K., & Sills, M. R. (2024, January). Unwinding of Continuous Medicaid Coverage Among Patients at Community Health Centers. In JAMA Health Forum (Vol. 5, No. 1, pp. e234622-e234622). American Medical Association.↩
- The analysis excludes duplicate responses and responses from state Primary Care Associations, which are nonprofit organizations that represent CHCs on policy and programmatic issues.↩
- Tolbert, J. & Ammula, M. (2023). 10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision. KFF. Accessed April 1, 2024 at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-un…↩
- CDC (n. d.). Disability and Health Information for Health Care Providers. Accessed April 1, 2024 at https://www.cdc.gov/ncbddd/disabilityandhealth/hcp.html#:~:text=Studies…↩
- CMS (n.d.). State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. Accessed April 1, 2024 at https://data.medicaid.gov/dataset/6165f45b-ca93-5bb5-9d06-db29c692a360/….↩