Dan Gorenstein: What’s happening in Medicaid right now is unprecedented.

News clip: A lot of Americans are just hours away from losing their Medicaid benefits. 

DG: For three years, the federal government gave states extra money to keep people on the Medicaid rolls during COVID. Now…

News clip:We are in the middle of something called the Medicaid unwinding…
News clip: States will start looking at their Medicaid rosters, and redetermining whether or not people should still stay covered. 

DG: … states are rushing to review the eligibility of more than 90 million people enrolled in the public health insurance program for low-income and disabled Americans.

News clip: The government estimates 15 million people will lose their health benefits in the next few months.

DG: Today, we check in on the biggest change to Medicaid since the Affordable Care Act, and get an up close look at what it’s like to fall through the unwinding cracks. From the studio at the Leonard Davis Institute at the University of Pennsylvania … I’m Dan Gorenstein. This is Tradeoffs.

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DG: To get a clear and nuanced picture of what’s been happening with the Medicaid unwinding so far, we called up one of our favorite Medicaid obsessives.

Adrianna McIntyre: Health insurance is the thing that gets me up in the morning. I realize how weird that sounds.

DG: Adrianna McIntyre is an assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health and a member of the Tradeoffs Advisory Board. To Adrianna, health coverage in America boils down to two questions: 

AM: Getting people covered and then keeping them covered. I think that a lot of research up to this point has focused on that first part. I’m really interested in how do we keep people covered once we have them insured.

DG: This is what makes Adrianna the perfect person to talk to about the steps states are — and are not — taking to keep people insured during the unwinding, whether by staying on Medicaid, switching to Obamacare or getting coverage through work.

AM: I think that this moment is both incredibly unprecedented and also entirely ordinary. Prior to the public health emergency, people who are on Medicaid did have to recertify their eligibility every year. But we didn’t really focus on it academically, as policymakers. And so this is one of the first times that we’re really getting a look under the hood at this process.

DG: So let’s dive under that hood, Adrianna. As of June 27, KFF says more than 1.5 million people have lost their Medicaid. That’s since April. And only half of the states are reporting their data. So here’s my question: About 70% of those 1.5 million people lost coverage due to what are called “procedural reasons.” Adrianna, can you define “procedural reasons” for us please?

AM: Procedural terminations happen when a state can’t determine for sure whether or not a person is still eligible for Medicaid, and oftentimes this happens because the state wasn’t able to get ahold of the enrollee to get information they need like that person’s income.

DG: So if a person loses coverage for “procedural reasons,” they might still be eligible, they might not. All we know is there was some kind of paperwork problem that the state had.

AM: Yes. Maybe the paperwork didn’t get to them. Maybe it’s not in a language that they’re familiar with. And there’s going to be a real human cost to this, because are people going to show up for a medical appointment thinking they have insurance, and find out that actually they don’t have coverage?

DG: And this is a problem whether you legitimately qualify for Medicaid or even if you, for example, make too much money now, and are no longer eligible. 

AM: Right. It’s a really big problem if people lose Medicaid benefits that they still qualify for but if somebody is determined ineligible, that’s not the end of the story for them either. We have to make sure that they get into some new source of coverage before they need it.

DG: So we’ve got these big scary numbers: 1.5 million people losing coverage, 70% for procedural reasons, unknown reasons. Are things this bad everywhere, Adrianna or as is often the case with Medicaid, does the story look different state by state?

AM: This really does vary a lot by state. In some states, I think the scary headlines track really closely with what we’re seeing. In some other states, things maybe don’t look quite as bad. And then there are states where we just don’t have enough data yet to say how things are playing out on the ground.

DG: Got it. So let’s zoom out to a few different states so we can kind of better understand what these differences actually look like. And let’s start with a state where the spooky headlines are in fact, warranted, where things are looking bad. Where’s a state like that?

AM: So Florida is one of the states that I’m particularly concerned about. So far they’ve terminated coverage for about 300,000 people which is more than twice as many as the next highest state. Florida is one of the states that hasn’t expanded Medicaid under the Affordable Care Act which means that a lot of people losing coverage may not have access to other sources of affordable health insurance. In the first month in particular, we saw a really high rate of those procedural terminations in Florida. Florida is also one of only two states that has not taken advantage of any of the flexibilities that CMS has given to states to try to make this process more seamless.

DG: CMS is of course the federal Centers for Medicare and Medicaid Services which oversees the Medicaid program for the federal government. So if Florida is an example of a state that has you legitimately concerned, what’s a state where things are going better? 

AM: So I would take us to Rhode Island with the caveat that it’s one of the states that didn’t start terminating people’s coverage until June. But Rhode Island is a state that’s always been really good at automatically determining people’s eligibility and basically keeping them enrolled in the program without bothering them. And so only about a quarter of people who are up for renewal had their coverage terminated and about half of those were for procedural reasons. So it seems like fewer people are slipping through the cracks in Rhode Island. 

DG: So as you give us this tour kind of up and down the coast from Florida to Rhode Island, it is very clear how this is a state by state story. At the same time, I’m curious, are we seeing any states sort of pause or in real time try to shift what they’re doing to minimize the damage being done?

AM: So Idaho saw a rate of procedural terminations that was higher than they expected, and they decided to pause those procedural terminations until they could figure out what was going on. Iowa is another state that they didn’t exactly pause, but they have implemented what they call safety checks to ensure that they aren’t acting too hastily to close people who may have complied with everything that they needed to do from a paperwork standpoint.  

DG: And, Adrianna, what about the federal government, CMS? Are they getting involved at all?

AM: CMS has authority from Congress to pause procedural terminations if they think that a state isn’t being responsible. We haven’t seen CMS take steps yet, although we have seen Secretary Becerra put out a letter basically imploring states to slow down if their procedural termination rate is high and take advantage of the flexibilities available to them to try to make this process less onerous.

DG: Are you surprised that there are not more adjustments being made at the state level in real time?

AM: Yes and no. Seeing these numbers, my instinct is that states should stop, reevaluate make changes and then proceed. At the same time, it’s maybe not as easy as it sounds because I think that a lot of the changes can take weeks or months to implement. You know, the data infrastructure piece of this, it’s not sexy, but it’s really, really important. And the states might just feel like they don’t have enough time to get those changes done and still get the redeterminations done on the timeline that they’ve set out for themselves.

DG: A lot of the focus, Adrianna, during the unwinding has been on people losing Medicaid who are still eligible. But as you said earlier, there are also a lot of people who no longer qualify for Medicaid but could get an Obamacare plan. I know you’ve done a lot of work in your career on how hard it’s been historically to do that. Do we have any data or sense of how those transitions are going right now?

AM: We don’t have as much data as I would like, although you could say that about a lot of things.

DG: Pretty much every researcher I’ve ever talked to in my entire life.

AM: Yes. Yes. There’s one state that I’ve seen publish this data, and that’s Pennsylvania. They found that about 6% of people who left their Medicaid program took up coverage with the state’s insurance marketplace. CMS has put out a little bit of data suggesting just in general that there’s been more shopping on healthcare.gov in states that have started unwinding, but I would love to see more granular data on that.

DG: So final question: We’ve still got another 11 months for states to finish reviewing eligibility of tens of millions of people. As you sit here in June, what questions, Adrianna, are on your mind as you look ahead to the rest of this unwinding process?

AM: I’m really curious, now that we have a clearer picture of how different states conduct redeterminations, will we try to set better standards so that the low performing states have to become higher performing states? Another thing that I’ve had in my mind for a little bit is we’re getting this data right now because it’s required by law for states to publish this until April of 2024. Will we continue to see states publish this data so that we continue to have transparency and insight into these processes so that we can see where people are slipping through the cracks. We can’t fix cracks that we can’t see.

DG: Adrianna, thank you so much for taking the time to talk to us on Tradeoffs. We really appreciate it. 

AM: Thank you for having me.

DG: When we come back, we travel to the Midwest to see how the unwinding is playing out on the ground in Ohio.

MIDROLL

DG: Welcome back.

As we heard from Adrianna McIntyre, the story of Medicaid unwinding is really 51 stories with each state and Washington D.C. doing things a little bit differently. And she gave us a high level look at how things are going in a few states. But we wanted to zoom in even deeper, so we called up another friend of the pod.

Farah Yousry: I’m Farah Yousry, and I’m the managing editor of Side Effects Public Media.

DG: We asked Farah to help us understand what this looks like for real people on the ground in a single state.

FY: I really wanted to talk to someone who was at risk of falling through the cracks, losing their Medicaid even though they still qualified. But I also wanted to hear from people on the other side too, the Medicaid workers who are spending their days processing all these cases. 

DG: Farah found those people in the Buckeye State. According to KFF, nearly 100,000 people in Ohio have already been kicked off Medicaid this year — 3 out of every 4 for “procedural reasons.” Farah picks up the story from here. 

FY: Bobby Summers cuts an impressive figure. He’s 42, well-built with a deep tan from years of doing physical jobs like logging and farm work.

Bobby Summers: I used to drive down the road and think like, what would my dream job be? And I would picture, like, me pulling into a farm or something, and working with a good close group of guys and just doing different stuff. 

FY: But on this sunny, warm May day, Bobby’s terrified. He arrives at Southeast Healthcare, a community health center in Columbus, clutching a letter in his calloused hands. The letter is from the state and it says that he will lose his Medicaid in less than three weeks. Losing his health insurance is not an option, Bobby says.

BS: I take some mental health antidepressant medication. And the last time I went without it, they stopped it for about 10 days and I just fell apart. 

FY: On top of his depression, Bobby takes medication for opioid addiction — something that landed him in prison for 8 years. He was released in late 2021 into a world he hardly recognized. He had never seen an iPhone. He didn’t know what an app was and couldn’t figure out how to pay for parking.

BS: It’s been a roller coaster, you know, but I’ve never stopped my path. Everything else around me has gone up and down and sideways.

FY: One surprising constant: Medicaid Bobby signed up as soon as he left prison and thanks to the special pandemic rules preventing states from kicking people off, he’s taken care of himself. He’s reliably gotten his depression and addiction meds. He’s consistently come in to the clinic for mental health appointments.

BS: I became who I am today because of it, you know, I would have been dead otherwise.

FY: But on this May morning, Bobby feels like his back is against the wall. On the same day he got his Medicaid news, he was also laid off from a farm job. Without Medicaid, there was no way Bobby could afford his medications, which can cost up to $1,200 a month. That’s why he’s come here. He’s at the health center a full hour early for his appointment with Kathryn Bamberger.

Kathryn Bamberger: So, first thing before we talk about anything, I’m going to ask you to sign this…

FY: Kathryn’s job is to help people like Bobby figure out their health insurance. Bobby sits across a circular table from Kathryn and hands her the 8-page neatly folded letter from the state Medicaid office. Bobby’s nervous but attentive, crossing his legs and sitting up straight to answer Kathryn’s questions. Kathryn raises both eyebrows as she goes through the letter. She’s alarmed. The state claims Bobby failed to send in paperwork to prove he makes less than the state’s Medicaid cutoff limit, about $1,600 a month. Bobby tells her he sent it. So Kathryn dials a number on her phone. 

Phone line: This call may be recorded for auditing, quality and training purposes…

FY: She calls the Ohio Jobs and Family Services office which manages Medicaid. 

JFS: How can I help you?
KB: Hi, my name is Kathryn Bamberger and with me here is Medicaid client Robert Summers…

FY: She nods to Bobby, encouraging him to tell the caseworker on the phone what happened. 

BS: I received that paperwork a couple of months ago and I filled it all out and mailed it back in but I don’t know if you guys didn’t haven’t received it or what.
JFS: No, we didn’t get it.
BS: It’s been probably two months now since I mailed it.
JFS: Okay, well It doesn’t look like the county has received it. 

FY: The caseworker explains Bobby’s best option is to create an online account and upload all of his documents again. 

BS: My prescriptions are 28 days at a time. So in 28 days from today, would I be able to have my prescriptions filled? If I get this stuff turned in today?
JFS: If you get it turned in, they should have it working. You should be fine. 
BS: Okay.

FY: After 18 minutes, the call ends.

KB: Okay, thank you very much. Sure appreciate it.
JFS: Oh, you’re welcome. Thank you guys, have a great day. 
KB: You too. Bye bye.

FY: Kathryn jumps into action. She helps Bobby create that online account. They upload his tax returns, his proof of income and email them directly to his caseworker. By the time Bobby stands up to leave, he’s been at the clinic for 2 hours.

BS: I mean, I couldn’t imagine like the guys and girls that don’t have somebody like you to help them do this I would not be able to figure all this out.

FY: Bobby walks out of Kathryn’s office full of emotions: thankful for Kathryn’s help, angry at Medicaid for making him jump through so many hoops, and scared that he won’t have insurance to help him cover his meds the next time he goes to the pharmacy. 

BS: You know, like, basically my life hinges on it. Without it I have a really hard time. And I don’t want to think about feeling like that again. 

FY: As Ohio grapples with this unprecedented task, nearly 100,000 people have already lost their coverage, even though some of those people are still eligible for Medicaid. Joel Potts is the executive director of the Ohio Jobs and Family Services Directors Association, which represents the state’s 88 Medicaid offices. 

Joel Potts: We’ve never seen anything like this. 

FY: Joel says leading up to the unwinding, counties struggled to staff up, some of them staring at 20% vacancy rates.

JP: And if they’ve got a 20% vacancy, I put money on it, at least 20 to 30% of the staff that they have are newer.

FY: Joel says so far, things are going better than he expected. Half of people’s coverage has been renewed automatically thanks to updates to Ohio’s data systems, and nearly 25,000 people who now make too much for Medicaid have been offered help finding affordable private insurance. All told, counties are getting through 96% of cases each month, according to state officials. But Joel says those unfinished cases could build up month after month, and without enough case workers, delays happen and things get missed.

JP: You know, the shopping day after Thanksgiving? You know you’re going to wait in long lines because they don’t have the staff to handle that. That’s what we’re looking at is our own Black Friday, but it’s going to last 12 months

Cindy Gauder (on phone): Hi, this is Mrs. Gauder at Job and Family Service. I believe you called just a moment ago.

FY: Cindy Gauder’s been working at the Medicaid office in Greene County, Ohio for two decades. 

CG (on phone): The message was a little garbled, but couldn’t make out. What was your social?

FY: She knows how important her job is, especially right now. She says her office has luckily avoided major staffing shortages. Still she’s had to work overtime almost every other Saturday the past two months to get through all the cases. She says a straightforward case typically takes her around 20 minutes. But oftentimes things get tricky.

CG: It’s a complicated system, you know, there’s days that I’m just like, ‘What are you doing?” I talk to my computer quite often, not always nicely.

FY: Cindy spends a lot of her time tracking people down. First, she sends a renewal packet to the last address she has on file for someone. But many of those packets never make it back, or if they do, they end up back in Cindy’s cubicle marked “return to sender.”

CG: Maybe they’ve moved and not reported that then we’ve got that renewal packet that we know didn’t get to them.

FY: When that happens, Cindy turns to the phone. She tries a client with some missing paperwork.

CG: Well, that went straight to voicemail. So my thought is that it probably isn’t a good number for her anymore.
FY: And you tried another number before?
CG: Yeah, and the other number was not a working number. 

FY: Ohio has spent the last 18 months reaching out to people with Medicaid to get them to update their contact information: flyers, text messages, social media posts. They’ve also worked with community organizations like food banks to spread the word. Despite all that, Cindy and her co-workers are having a hard time finding people. And Cindy’s job is more than just Medicaid. She helps people looking for housing, food and cash assistance too.

CG: Some days are a little more difficult than others. Sometimes I feel like I just chase my tail all day. 

FY: Cindy gets it. People are struggling with jobs, family, just surviving. Responding to government calls and emails falls to the back of the line. That’s why when Cindy does get a hold of a client, she makes sure to see their case through. She remembers one woman who had just been diagnosed with cancer who called about her Medicaid.

CG: She started to cry when I told her I said your Medicaid is approved. I gave her a billing number you can call, make a doctor’s appointment. 

FY: Cindy sighs. She says calls like that are hard to come by this summer. I got my own window into Cindy’s world of missed calls while reporting this story. After meeting Bobby in May, I struggled to reach him right before his Medicaid was set to end. So I called Kathryn, the insurance navigator. Kathryn pulled up his account on her laptop to check his coverage status.

KB: No. He does not have Medicaid. It ended yesterday.
FY: Really?
KB: Yeah. We updated all that stuff.
FY: Wow. Now what?
KB: I’m very disappointed. We put a lot of work into this. We attached his stuff. Man.

FY: I reached out to the Medicaid office. Turns out, it took county officials 20 days to review Bobby’s case because of the backlog. After they finally reviewed his documents. They re-enrolled Bobby immediately.

BS (on phone): Hi, Farah.
FY: Hi Bobby. How are you? 
BS: I’m doing okay. How are you doing?

FY: I caught up with Bobby. He was on his way from a job interview at a specialty doors factory. He told me between losing his job and going through his Medicaid off-again, on-again process, it’s taken a toll.

BS: This has been the hardest thing that I think it’s ever happened to me, really, even harder mentally than prison.

FY: He says he’s thrilled to have his Medicaid coverage back, that he won’t have to choose between groceries and medications — for now. He also knows some people won’t be as lucky.

DG: Side Effects Public Media’s Farah Yousry. I’m Dan Gorenstein, this is Tradeoffs.