Biden urged to get tough as millions lose Medicaid

Millions of people are being pushed off state Medicaid rolls as the U.S. dismantles one of the last major Covid-era safety nets, and congressional Democrats and health advocates want the Biden administration to do more to ensure people are protected. 

Nationwide, nearly 5.5 million people have been purged from state Medicaid rolls across 45 states and the District of Columbia, according to health policy research group KFF. 

At least 1 million of them are children, though that number is likely higher because not every state reports by age. 

Most people have been removed for "procedural" reasons, like missing or incorrect paperwork, or when the state has outdated contact information, even though they may still be eligible. 

Last year, Congress gave the Centers for Medicare and Medicaid Services (CMS) more power to ensure that states are not improperly removing Medicaid beneficiaries. The agency can tell states to pause procedural terminations, file a corrective action plan, or even yank federal funding.

"We certainly would like to see the Biden administration take swift and decisive action to use their enforcement tools as needed, when the number of children losing coverage is high, and in particular, when there are a lot of procedural terminations," said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

On Capitol Hill, Democrats have been calling on the administration to take more aggressive action against states that don't try to slow high rates of procedural unenrollment.

Lawmakers have been raising concerns since states started reporting data in June.

At the time, Senate Finance Committee Chairman Ron Wyden (D-Ore.) and House Energy and Commerce Committee ranking member Frank Pallone Jr. (D-N.J.) urged CMS to threaten to withhold funding from state Medicaid programs if they don't undertake good-faith efforts to prevent procedural terminations.

Most recently, the entire Texas Democratic delegation, led by Rep. Lloyd Doggett, sent a letter to CMS on Aug. 22 urging "swift intervention ... to prevent the catastrophic loss of coverage occurring in Texas, which already has the disgraceful distinction of the most uninsured people in the country."

Texas reported more than 600,000 residents had their health coverage terminated over the past four months. Nearly half a million of them were children, and nearly 400,000 had their coverage ended because of red tape.  

Experts said Texas should be considered an outlier because it has such a large Medicaid program — and since it hasn't expanded Medicaid like most states, the majority of its enrollees are children.

"But the fact that 81 percent of disenrollment were among children, but they only comprise 72 percent of total enrollment, it does suggest that perhaps ... there may be cause for concern," said Jen Tolbert, director of the State Health Reform and Data Program at KFF.

In addition, whistleblowers in the state Department of Health and Human Services (HHS) identified nearly 100,000 people who had their health coverage ended after they were erroneously booted from the program.

While the state has been working with the federal government to reinstate coverage to those impacted, Doggett and the other Democrats said they don't have confidence the state will protect people. They urged CMS to step in and pause the process before the next round of redetermination begins Sept. 9.

"To date, the [agency's] response has been nominal and failed to ensure Texas fulfills its responsibility to families," Doggett's office told The Hill. 

An agency spokeswoman said, "Texas is currently in compliance with CMS unwind requirements," in response to questions from The Hill.

"Redetermining Medicaid eligibility for approximately 6 million Texans over 12 months is a massive undertaking, and HHSC has planned this unwinding effort for more than a year."

Before the pandemic, people churned in and out of Medicaid for various reasons. Participants lost their coverage if they earned too much or didn’t provide the information needed to verify their income or residency.

But during the public health emergency period, income changes or missed paperwork didn’t matter. If someone was enrolled in Medicaid in March 2020, or if they became eligible at any point during the pandemic, they remained eligible the entire time.

As a result, Medicaid enrollment grew more than 30 percent and covered more than 90 million people. 

But Congress ended those protections, and states have been able to reassess eligibility and kick people off Medicaid rolls since April.

CMS has expressed concern for months that many states are rushing through the process, but the administration has largely tread lightly. 

Most of the communications with states have been behind the scenes. To date, CMS said it has required 14 states to pause Medicaid disenrollments for part or all of their populations.

But CMS did not identify which ones. Officials have been reluctant to single out individual states, or even say what might trigger stronger federal action, though there's hope that approach may be changing. 

Earlier this month, the agency sent letters to state health officials in all 50 states and D.C., warning that many are failing to meet federal requirements about determining Medicaid coverage. It was the first time the agency publicly disclosed its oversight and enforcement priorities.

The letters flagged three key areas of concern: high rates of procedural terminations, long call center wait times and call abandonment rates, and slow application processing.

While much of the attention has been on the Republican-led states rushing through the process, the letters cited a total of 36 states for at least one problem, including blue states. 

A Senate Democratic aide said those letters were viewed as "a step in the right direction," but there are still concerns over the degree of coverage losses. 

Tolbert said while she appreciates CMS not wanting to publicly call anyone out, it's hard to tell how much of an effect the agency's efforts are having.  

"Because we don't know where CMS is pushing and which states they are pushing, we're just having to guess whether those actions are having an effect, or as strong as perhaps advocates and others in the state might want to see," she said.

A CMS spokesperson said the agency "takes its monitoring and oversight role during Medicaid and CHIP renewals incredibly seriously, and is doing everything in its power to help states to go above and beyond the minimum requirements to keep people covered." 

It added, “We will not hesitate to hold states accountable for failing to follow federal requirements."