Twelve years ago, Congress approved, and President Obama signed the Affordable Care Act (ACA) into law. And what started as a small program that provided health coverage to people on cash assistance was cemented as the most impactful health insurance program: Medicaid.
Medicaid was first approved in 1965 as a part of Lyndon B. Johnson’s great society. While Medicare provided health coverage to seniors, Medicaid was envisioned as a more limited program for low-income pregnant women and people with disabilities. But over the forthcoming decades, it’s been expanded and reformed to become the largest health insurance program in the country: covering 80 million lives, paying for nearly half of all births, and protecting 10 million people with disabilities in addition to millions more who need long-term care.
During the pandemic, Medicaid and the ACA served as a safety net as many people lost jobs. Though the pandemic led to huge economic and employment downturns, the number of uninsured people actually fell by 0.6 million, or 1.9%. This was in stark contrast to the Great Recession of 2008-2009 when 9.3 million people lost their jobs and, subsequently, their health insurance — roughly 9.5% of children were uninsured. This time, safety net programs like Medicaid and subsidies available through the ACA kept people from losing health care coverage. Medicaid and CHIP enrollment increased to 83.2 million, up nearly 18% since February of 2020 and enrollment in Marketplace plans increased from 11.4 million in 2020 to 14.5 million in 2022. This was largely in part to the expanded subsidies pushed by the Biden administration and approved through the American Rescue Plan Act (ARPA).
But all this progress is now in jeopardy. Throughout the pandemic, states have been obligated to keep people covered through Medicaid in exchange for higher payments from the federal government. But when the national declaration of a Public Health Emergency expires, states will lose the enhanced Medicaid funding and be required to conduct eligibility determination on all 83.2 million enrollees.
The risk is that the administrative process of chasing down enrollees and making them mail in the proper documentation will inadvertently kick-off millions of eligible people — putting them at risk for economic and physical harm.
The Biden administration has been working to streamline the redetermination process, saying that it can take up to 12 months to complete the renewals. States are also being asked to outline how the process will work, and how they will connect ineligible people with other forms of coverage, such as through the ACA exchanges.
Many states lost workers during the pandemic. That compounded with poor technology, outdated addresses, and the heavy lift of determining eligibility could leave many people left uninsured — intentionally or unintentionally. Red states, particularly those who resisted Medicaid expansion, could use it as an opportunity to “purge” Medicaid roles for political reasons. There are still 14 states that haven’t expanded Medicaid to cover all low-income residents and others that only expanded begrudgingly under state referendum.
The Urban Institute estimates roughly 16 million people who currently have coverage will be found ineligible. Of the adults, roughly a third should be eligible for federal tax credits for ACA private plans — if they enroll during the so called “special enrollment period.” But millions could slip through the cracks without a concerted effort to connect them to available resources, undoing the successes of the ACA right after it proved its utmost utility during the worst pandemic in modern history. States should take advantage of new flexibilities put in place by the Biden administration to simplify the redetermination process for beneficiaries and make the transition between Medicaid and private insurance as smooth as possible and Congress should make the enhanced ARPA subsidies permanent.
