DG: In the last three years, the number of people on Medicaid — the public health insurance program for low-income and disabled Americans — has ballooned. 

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It’s gone from 71 million to more than 90 million after Congress effectively blocked states from kicking people off the rolls in the middle of a global pandemic.

But starting on April 1 … 

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DG: Over the next year, an estimated 15 million people could lose their Medicaid coverage. Some will get insurance through work or Obamacare, but millions who are still eligible are expected to end up uninsured.

Today, University of Minnesota health economist Sayeh Nikpay shares three studies to help explain what is happening and how states and employers could keep more people insured.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

*****

DG: Sayeh Nikpay, what’s happening, my friend, so nice to see you.

SN: Nice to see you too. 

DG: How are you? How’s the family?

SN: I’m good. I’m preparing for Persian New Year and digging out of inches of ice, and yeah, enjoying life.

DG: Do you have one of those ice chopper things?

SN: I have an ice chipper, and I channel all my frustrations into chipping ice. I did it for three hours today. It was great, best workout.

DG: I love an ice chipper. We don’t get to use them much in Philly anymore unfortunately.

Setting aside your rage that you’re getting out on the ice, let’s talk a little bit about Medicaid.

You’re here to tell us about the 15 million people who could lose their Medicaid over the next year.

With the pandemic easing, Congress voted last December to let states restart the process of clearing their rolls, and this all starts April 1.

SN: That’s right. 

And to put that 15 million in context, I remember how we were all geeking about that 7 million people had gained Medicaid in the first few years of Obamacare. So 15 million people losing Medicaid, Dan, that is historic.

And I should say, this is an estimate, but the federal government and the independent Urban Institute both projected around 15 million people will lose their Medicaid.

DG: And, Sayeh, before we dive into what may happen to these 15 million people, let’s set the baseline.

In terms of the evidence, what do we know about having Medicaid coverage? What does it actually mean for people?

SN: So there’s a Mt. Kilimanjaro sized pile of evidence on Medicaid, Dan.

DG: That’s a lot. That’s a lot.

SN: It’s a lot. And it shows that Medicaid is associated with better access to care, more financial security, better health and even lower mortality.

I’m thinking about the Oregon Health Insurance Experiment, which showed Medicaid improved people’s financial security and mental health outcomes, and recent papers published in top economic journals that show Medicaid literally saved lives.

DG: And what about having Medicaid continuously throughout the pandemic, Sayeh? Is there any evidence on that?

SN: Yeah, unfortunately it’s too soon to tell because it usually takes a couple of years to get the data to get what we need to come to those kinds of conclusions. But anecdotally, the Kaiser Family Foundation did some focus groups with people who have been on Medicaid during the pandemic, and they say things like it’s helped get care more easily, and it’s been a safety net after losing a job, and one person simply put “having the security of Medicaid is everything.”

DG: But I also have to imagine that keeping all these people on Medicaid has not been cheap.

SN: Absolutely. Medicaid spending jumped 9% between 2020 and 2021. That’s about triple what we normally see.

DG: Okay, so losing this coverage could really matter for people’s physical and financial health, but it could also save states and the federal government a pretty penny.

Real quick, Sayeh: What’s literally going to happen over the coming months that will lead to people losing coverage?

SN: So Medicaid eligibility is usually tied to people’s incomes, and they have to regularly prove that they still qualify — what’s known as “redetermination.”

DG: Right, in the 39 states and Washington D.C., that have expanded Medicaid, a family of four has to make less than $40,000. In non-expansion states, it’s even less.

SN: Exactly. Now, some states automate this process, but it can often require a lot of paperwork or even face to face interviews. That’s what Congress basically blocked state Medicaid offices from doing during the pandemic.  But now Congress is giving states 14 months to do three years worth of determinations.

And, Dan, we’re talking about Medicaid offices that are often underfunded and dealing with serious staffing shortages.

DG: A pretty tall task.

SN: It’s going be a big lift, Dan. States have never had to do this many redeterminations this quickly before, and there’s a lot of uncertainty about what will happen.

DG: But something I love, Sayeh, about you health economist types is when faced with uncertainty, you guys run to the data. 

You’ve brought three papers that give us a sense of what could happen to these 15 million people.

Can you just tell us about the first one?

SN: So the paper is the one that actually reports the estimates of how many people could lose coverage starting in April. It’s from ASPE, the Office of the Assistant Secretary for Planning and Evaluation, which is like the research department for federal health officials. And their report makes it clear that these 15 million people who could lose their Medicaid are not all the same.

DG: What do you mean? 

SN: Well, the report breaks them into two groups. The first group are people who now make too much money to qualify for Medicaid. ASPE estimates there are about 8 million people in that group, and these folks should be able to get insurance through their jobs or on the Obamacare exchanges.

DG: OK so that leaves about 7 million people. What’s up with them? I’m assuming they are still eligible for Medicaid?

SN: You’re right, Dan, they are still eligible. They could lose coverage because of what’s called “administrative churn.” This is where people end up getting kicked off of Medicaid because of basically paperwork issues, even though financially they still qualify.

DG: And what do “paperwork issues” look like, Sayeh? 

SN: Well, sometimes people move or change their phone number and the Medicaid office can’t get ahold of them to let them know they need to reapply. Folks might miss an in-person appointment because they have work or child care responsibilities too.

So we’re talking about 7 million people, typically with very low-incomes who may work, but in jobs without health benefits, and they could end up uninsured.

DG: This is really the core tension of this whole process, right?

On one hand, states want to shed the people who make too much money, but Medicaid officials also know eligible people will end up losing coverage too. It’s what happens when they do redetermination. But given how big and fast it’s all happening this year, it seems like there’s more room for things to go wrong, meaning people get hurt. 

SN: That’s right. The federal government is giving states 14 months to work through this backlog to try to minimize the hurt, but some states are going faster. Arkansas for example is planning to redetermine tens of thousands of people in just six months.

DG: So for the last three years, people on Medicaid have been on the program without having to think about all this paperwork. Do they even know this redetermination is coming at them?

SN: This to me is one of the scariest parts, Dan. The Urban Institute did a survey in December that found nearly two-thirds of adults on Medicaid had no idea they had to start confirming their eligibility again.

DG: When we come back, Sayeh looks to the research for insights on what can be done to help people in both of these groups stay insured.

MIDROLL

DG: Welcome back.

I’m here with Tradeoffs Senior Research Advisor Sayeh Nikpay, who’s brought in several papers to help us understand what could happen when — for the first time in three years — states begin to reassess who is eligible for Medicaid on April 1.

Sayeh, your first study laid out the two groups of people who could lose their coverage. The first are folks who now make too much money to qualify — that’s about 8 million people. And the second are people who are still eligible but may get kicked off for administrative reasons. Maybe their address changed and never knew they needed to reapply, and that’s about 7 million people. And this whole redetermination process is enormous.

SN: So the good news, here, Dan, is that I’ve got a paper about each of these groups, and they offer policymakers a bit of a roadmap to keep as many people insured as possible.

DG: Sounds good. Let’s start with people who make too much money. 

SN: So first off, a lot of folks in this group should be able to get insurance through work or the Obamacare marketplaces. But getting them into those plans is harder than it sounds.

DG: The devil is in the details, I know a health economist’s favorite phrase. Why don’t you tell us about the paper, Sayeh. 

SN: It’s actually from our own Tradeoffs Advisory Board member Adrianna McIntyre, who’s an assistant professor at Harvard. She published a paper in JAMA Health Forum last October that looked at the most effective ways to move people from Medicaid onto private plans on the exchanges.

There’s not a ton of data on this, Dan. But based on the few studies out there, Adrianna found that only 3 to 5 percent of people who leave Medicaid end up getting an Obamacare plan.

DG: I guess that’s what you mean when you say this is harder than it sounds.  

SN: Yeah, you know, federal health officials estimate about half of these 8 million people should get covered through work. That leaves the other half. And I think it’s easy for health policy people like me to assume the exchanges will be a life preserver for those folks in this moment. But Adrianna’s work shows us that the more Medicaid does to help people “swim” the more likely they are to stay insured.

DG: Nothing like a good ol’ Sayeh Nikpay metaphor!

SN: Thank you.

DG: Go on.

SN: So she cites several randomized controlled trials where states tested different ways of increasing enrollment in Obamacare plans. And these studies found that simple reminders from the state like physical letters, emails, phone calls — they helped get people enrolled. They boost sign-ups anywhere from 7-16%.

But what really seems to make a difference is reminders plus a little bit of hand holding — connecting people to someone who can get them signed up while they are on the phone together. In one of those trials published in 2022, people in California who got a reminder email and a call connecting them to enrollment assistance were almost 50% more likely to sign up for a plan.

DG: So based on the research we have, the most effective way to make sure people get signed up for a new plan is for someone to personally reach out to them and help them through the process? That’s really the takeaway?

SN: Exactly. Obviously hiring a bunch of people to call tens or hundreds of thousands of people is going to cost a lot of money, which states may not see as a priority or see as financially feasible.

DG: So that’s what the state can do to help people transition from Medicaid to other insurance. What about employers, since a good chunk of these 8 million people are expected to get coverage through their jobs? Any research on what employers can or should do?

SN: Nothing directly, Dan. But based on the evidence we do have, making sure people know their Medicaid is going away and giving them as much help as possible seems like a good thing employers could do this spring.

DG: Alright, Sayeh. Your last study. Hit me.

SN: So let’s go back to our other group: the 7 million people who may lose Medicaid even though they are still eligible. We know that people will lose coverage due to that administrative churn: missing a phone call or a piece of mail reminding them to reapply. Some states have tried to limit that churn, and there’s a study by researchers at the RAND Corporation on New York’s Medicaid program, which for years now has allowed people to stay on Medicaid for a full 12 months once they’re enrolled.

DG: So that means in New York, people don’t have to worry about all the paperwork of constantly proving their eligibility, which should cut back on people getting kicked off Medicaid even though they’re eligible.

SN: Yeah, and what’s really cool is researchers found that people were less likely to get kicked off, but they also found that once this policy was in place, hospital admissions and monthly costs went down. Which suggests that avoiding that “administrative churn” can help people stay covered without ballooning costs.

DG: So how should states think about this finding? If the state of Minnesota called you up and asked you to advise them on redeterminations for Minnesota, what would you tell them about this study?

SN: I think I’d tell them that it makes sense. We can’t say that these outcomes — the lower monthly health care costs and fewer hospital admissions — are a direct result of New York’s 12-month policy. There was no comparison group to gauge what happens when people don’t have continuous coverage. But the question I always ask myself with evaluation studies like this is does the result make sense given everything we know? And I think it does. It seems reasonable to me that making it easier to stay on Medicaid — even outside of a global pandemic — could benefit people’s health given what we know about how Medicaid affect on health, going back to some of the research we talked about at the beginning of the show. 

DG: Right, better access to care, more financial security, improved health and even lower mortality. Sayeh, after digging through all this research, what’s your big takeaway? What does the research tell us about what this next year is going to look like as states start pruning their Medicaid rolls?

SN: I think it’s going to be a really hard year for a lot of people. It’s going to be hard for Medicaid workers, many of whom have never done a redetermination before and now are going to have to do A lot of them in a very short period of time. It’s going to be hard for the millions of people who need to figure out how to go from Medicaid onto private health insurance. And it’s going to be maybe the hardest on the nearly 7 million people who should be able to stay on Medicaid but they end up getting kicked off anyway and wind up uninsured.

Obviously Medicaid is incredibly political, but I think these last three years are a reminder that if a state wants to make sure that people who are eligible for Medicaid actually get it, it’s within their power.

DG: Sayeh Nikpay, it is always a pleasure. Thank you so much for being here.

SN: Of course, Dan!

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I’m Dan Gorenstein, this is Tradeoffs.