CENTER FOR POLICY ANALYSIS AND RESEARCH Health Equity The End of Medicaid’s COVID-19 Continuous Enrollment Provision July 2023
Tashia Roberson-Wing, John R. Lewis Social Justice Fellow
Introduction
In 2020, Congress passed the Families First Coronavirus Response Act (FFCRA) in response to the COVID-19 public health emergency. The enactment of the law ensured that statewide Medicaid programs, through the end of the COVID-19 public health emergency, had a continuous enrollment provision.1 The continuous enrollment provision was a requirement for states in exchange for additional federal funding.2 Since the pandemic, the number of people without health insurance has decreased while the number of people receiving Medicaid has increased primarily due to the continuous enrollment provision.3 On December 23, 2022, the U.S. House of Representatives passed H.R. 2617, the Consolidated Appropriations Act of 2023. The Consolidated Appropriations Act brought an end to Medicaid’s continuous enrollment provision on March 31, 2023, while phasing out the enhanced federal matching dollars.4 Starting April 1, 2023, states were able to purge individuals who did not meet the administrative requirements for Medicaid enrollment. States were given up to twelve months to begin returning to Medicaid eligibility and enrollment regulations that were in place prior to COVID-19.5
Access to health coverage is pivotal for obtaining health care and surviving high medical bills. Historically, there have been disparities in health care coverage among people of color compared to their white counterparts. Between 2019 and 2021, the increase in Medicaid health insurance enrollment rates, due to the continuous enrollment provisions, ensured increases in insurance coverage among all racial/ethnic groups.6 Despite the increase in health coverage amongst all racial/ethnic groups in 2021, 10.9 percent of non-elderly Black people were reported uninsured compared to 7.2 percent of non-elderly white people.7 With the end of continuous enrollment, the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation estimates that about 15 million people will be dismissed from the Medicaid program.8 Out of those predicted to lose Medicaid coverage, 4.6 million identify as Latino, and 2.2 million identify as Black.9 The end of continuous enrollment is detrimental to Black people accessing Medicaid and furthers the health care coverage disparities within the Black community.
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Background
The Federal Medical Assistance Percentage (FMAP) is a percentage that differs from state to state based on average per-capita income. The state’s total Medicaid expenses are reimbursed by the Centers for Medicare & Medicaid (CMS).10 Medicaid programs are managed through states, but the federal government helps share the cost by matching funds.11 The CMS is a federal entity housed under HHS that is used to administer federal dollars to states. FMAP takes advantage of the existing state Medicaid financial structures to funnel federal dollars without having to establish new policies to create new funding sources.12 This leads to federal funding being distributed to states more quickly. Increasing the percentage of federal funds allows for increased enrollment among those who are qualified and timely responses for needed health services.13
The FFCRA gave the federal government the authority to increase the Federal Medical Assistance Percentage (FMAP),which temporarily increased the federal government’s share of Medicaid costs among states.14 To help states answer to the Covid-19 public health emergency, Congress, through FFCRA, permitted a 6.2 percent FMAP increase to states with the exception that states abided by the maintenance of eligibility requirements.15 If states accepted the funds, they had to abide by maintenance of eligibility.16 The maintenance of eligibility requirements made certain that states upheld their Medicaid programs and did not cut coverages for beneficiaries.
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Impact of Ending the Continuous Enrollment Provision on the Black Community
Access to healthcare insurance is important for the overall mental, physical, and social health of a human being. Access to healthcare coverage provides opportunities to obtain affordable healthcare services, participate in preventative care, seek primary care doctors, and gain access to emergency services. Lack of coverage can impact a person’s access to a primary care doctor, mental health services, and preventative care. The ending of the continuous enrollment provision hinders access to life-affirming health care. Ending the continuous enrollment provision also leads to insurance churn. People who lose Medicaid and then reenroll are more likely to experience changes in doctors and disruptions in medication.
Because Black and Hispanic people are more likely to enroll in the Medicaid program, the sunsetting of the continuous enrollment provision will cause catastrophic gaps in coverage for Black and Brown communities and families. With potentially an estimated 15 million people losing Medicaid coverage, 4.6 million identify as Latino, and 2.2 million identify as Black.24 In 2021, the U.S. Department of Health and Human Services Office of Minority Health revealed that 42.7 percent of people who identified as non-Hispanic Black/ African American depended on Medicaid or other public health insurance.25 For the year 2021, the United States Census reported that 9.6 percent of Black/African American were living without health insurance compared to their white counterparts at 5.7 percent.26
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Total American Indian and Alaska Native alone, Not Hispanic or Latino Asian alone, Not Hispanic or Latino Multiracial, Not Hispanic or Latino Not Hispanic or Latino Some Other Race alone, Not Hispanic or Latino White alone, Not Hispanic or Latino Hispanic or Latino Black or African American alone, Not Hispanic or Latino 8.6 18.8 5.8 9.6 7.5 10.1 10.6 5.7 17.7 FIGURE 1
Percentage
Source:U.S.CensusBureau,2021AmericanCommunitySurvey,1-yearestimates.
of People without Health Insurance Coverage by Race and Hispanic Origin: 2021
Understanding that access to health insurance coverage is a social determinant of health, health insurance directly influences an individual’s health status and health outcomes. Research illustrates that African Americans face significant disparities regarding health status and health outcomes compared to white Americans.27 Non-Hispanic Black people represent over 12 percent of the United States population but when compared to the U.S. population experience chronic disease, morbidity, and mortality at a higher rate.28 A report from the U.S. Census Bureau disclosed that COVID-19, heart disease, stroke, cancer, asthma, influenza and pneumonia, diabetes, and HIV/AIDS contributed to the deaths of Black people at a higher rate than white people.29 There is a need for access to healthcare coverage in the Black community. The end of the continuous enrollment provision causes greater health disparities in the Black communitywhilewideningthequalityofhealthandhealthcoverageaccessgaps.
Policy Recommendations
To help alleviate the coverage loss expected due to the end of continuous enrollment provision, there are legislation recommendations that federal and state policymakers can consider
Expand the 12 months of continuous eligibility provisions: Twelve months of continuous eligibility is a tool that states use to guarantee that children have continuous health insurance through Medicaid and the Children’s Health Insurance program no matter the change in income/circumstance throughout the 12 months.30 Expanding the continuous eligibility provision within Medicaid could ease coverage loss and churn for those expected to lose coverage due to the end of the public health emergency.31 Continuous eligibility can offer individuals, who are expected to lose coverage under the conclusion of the continuous enrollment provision, more time to secure new coverage preventing gaps in coverage.
Expand Medicaid in all states: Medicaid expansion refers to the expanding Medicaid eligibility to almost all adults with incomes up to 138% of the Federal Poverty Level.32 States that decide to expand are provided additional federal funding towards their federal matching percentage. As of late, 40 states and Washington, D.C. have expanded, while 10 states haven’t opted into participating in the expansion.33 Within the states that aren’t expanding Medicaid, more than 300,000 people are expected to lose Medicaid coverage due to the end of the COVID-19 public health emergency. Expanding Medicaid could mitigate coverage loss.34
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26
Conclusion
Ultimately, states have the authority to end insurance coverage for individuals who do not meet the Medicaid requirements due to the end of the continuous enrollment provision. Black and Brown communities depend on Medicaid for health coverage. Black, Hispanic, Native Americans/Alaskan Natives and low-income people will disproportionately be impacted by the ending of the provision, causing greater health disparities in the Black and Brown communities. The unwinding of COVID-19’s public health emergency Medicaid provision will result in healthcare coverage shrinkages among those deemed eligible and ineligible for Medicaid because of administrative churn. Policymakers must implement equitable policies that create opportunities for affordable healthcare coverage for Black and Brown communities and prevent disturbances in healthcare insurance.
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References
1 Tolbert, J. & Ammula, M. (2023, April 5). 10 things to know about the unwinding of the medicaid continuous enrollment provision. KaiserFamilyFoundation https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-ofthe-medicaid-continuous-enrollment-provision/
2 Id.
3 Id.
4 Rudowitz, R., Burns, A., Hinton, E., Guth, M., & Tolbert, J. (2023, January 24). Medicaid: What to Watch in 2023. KaiserFamily Foundation https://www.kff.org/medicaid/issue-brief/medicaid-what-to-watch-in-2023/
5 Centers for Medicare & Medicaid Services. (n.d.). Unwinding and Returning to Regular Operations after COVID-19. Medicaid.Gov https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-andreturning-regular-operations-after-covid-19/index.html
6 Artiga, S., Hill, L., & Damico, A. (2022, December 20). Health Coverage by Race and Ethnicity, 2010-2021. KaiserFamily Foundation. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/
7 Id.
8 Office of the Assistant Secretary for Planning and Evaluation. (2022, August 19). Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches. U.S.DepartmentofHealthandHumanServices, Issue Brief HP-2022-20.
9 Id.
10 Centers for Medicare & Medicaid Services. (n.d.). 100% FMAP for LTSS — Educate Your State. CMS.Gov https://www.cms. gov/outreach-and-education/american-indian-alaska-native/aian/ltss-ta-center/info/100-percent-fmap-educate-your-state
11 Id.
12 Musumeci, M. (2020, May 4). Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19. KaiserFamilyFoundation https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-infederal-medicaid-matching-funds-for-covid-19/
13 Id.
14 Danner, R. (2023). Millions set to lose Medicaid coverage as the continuous enrollment provision ends. Georgetown JournalonPoverty&Policy https://www.law.georgetown.edu/poverty-journal/blog/millions-set-to-lose-medicaid-coverageas-the-continuous-enrollment-provision-ends/
15 Dolan, R., Musumeci, M., Tolbert, J., & Rudowitz, R. (2020, December 17). Medicaid Maintenance of Eligibility (MOE)
Requirements: Issues to Watch. KaiserFamilyFoundation. https://www.kff.org/medicaid/issue-brief/medicaid-maintenanceof-eligibility-moe-requirements-issues-to-watch/
16 Id.
17 Supra note 8.
18 Supra note 1.
19 Supra note 8.
20 Id.
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21 Id.
22 Centers for Medicare & Medicaid Services. (n.d.). What is Unwinding? CMS.Gov. Retrieved April 20, 2023, from https://www.cms.gov/aian-unwinding
23 Id.
24 Supra note 8.
25 U.S. Department of Health and Human Services Office of Minority Health Resource Center. (n.d.). Profile: Black/African Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61
26 Branch, B., & Conway, D. (2022). Health Insurance Coverage by Race and Hispanic Origin: 2021. U.S. Census Bureau.
27 Office of the Assistant Secretary for Planning and Evaluation. (2022). Health Insurance Coverage and Access to Care
Among Black Americans: Recent Trends and Key Challenges. U.S.DepartmentofHealthandHumanServices,IssueBrief No. HP-2022-07.
28 Id.
29 Supra note 25.
30 Centers for Medicare & Medicaid Services. (2021). Continuous Eligibility for Medicaid and CHIP Coverage. Medicaid.Gov https://www.medicaid.gov/medicaid/enrollment-strategies/continuous-eligibility-medicaid-and-chip-coverage/index.html
31 Supra note 8.
32 Kaiser Family Foundation. (2023, March 27). Status of State Medicaid Expansion Decisions: Interactive Map. KFF https:// www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
33 Id.
34 Supra note 8.
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CENTER FOR POLICY ANALYSIS AND RESEARCH
Health Equity
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