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The Great Unwinding: Medicaid disenrollments rise

As the Medicaid continuous coverage requirement ends, healthcare must stem a return to high numbers of uninsured patients


Desk with medical equipment, forms, and table with "medicaid" graphic
The Unwinding of Medicaid Continuous Coverage Requirement

It’s being called the Great Unwinding – the end of pandemic-era rules that allowed millions of Americans to qualify for Medicaid coverage and stay on it as long as the Public Health Emergency lasted. Those rules caused Medicaid enrollment to surge to more than 90 million people, an unsustainable drain on government coffers.



For hospitals and health systems, especially safety net providers, Medicaid has been an unlikely financial lifeline at a time when they sorely needed one. Despite low payment rates and variability in program design, Medicaid has helped manage the care of vulnerable and disadvantaged communities in states large and small, urban and rural. Imagine what last year’s financial losses would have been like with as many as 17 million additional uninsured patients.


Advocates for the disadvantaged, alarmed at the prospect of losing much of the gains in coverage in the past decade, have sought extensive state and local outreach about the redetermination process and sufficient staff to handle all the calls and paperwork involved. The language of the pandemic relief rules pointed to the hope of a soft landing for those who gained coverage but may have changed circumstances in the past two years, such as having found a better-paying job. States were urged to connect these folks to the subsidized Affordable Care Act marketplace plans or get financial assistance to purchase private coverage.


A number of states appear to be doing some of those things, but there is mounting evidence that many other states are using the return to routine eligibility checks to disenroll people who likely still qualify but who lack the means to fight a coverage determination or even find out they have been disenrolled. As the pandemic rolled on, many people lost their jobs and moved, as people in strained financial circumstances often do, leaving no forwarding address.


In April, just the first month of the Great Unwinding, Florida somehow managed to check the eligibility of 461,322 Medicaid recipients and booted 249,427 (or 54%) of those enrollees, including many children, from the program. In Arkansas, only one in seven of those who lost coverage did so because their incomes had grown to the point they exceeded Medicaid limits.


This is where having a mission of service comes in. It is incumbent upon providers and those of us in the vendor community to be proactive in helping patients get whatever coverage or financial assistance to which they are entitled. It also helps to be fluent in the applicable Medicaid rules and regulations in the states being served, something my company takes pride in.


In my view, Salud can and must take a leading role in this process. As our services include safety-net AR and patient self-pay, Salud has had thousands of interactions around Medicaid and ACA health plan eligibility. This is why I feel so strongly that offshoring these processes or continuing to engage in old-fashioned hardball collection tactics represent a failure to fulfill mission, vision and values.


Any commitment made to diversity, equity and inclusion must include a steadfast effort to protect the healthcare safety net, of which Medicaid is the backbone. If states are more focused on fixing budget gaps by getting as many people as possible off of subsidized care, it is up to us within healthcare to make sure people keep the coverage they are entitled to or find other affordable options.

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