Medicaid has become a significant safety net for families during the COVID-19 pandemic, with about half of all children in the United States now covered through their state’s public health insurance program for low-income and disabled Americans, including about 2.4 million kids in Florida.
But those gains in Medicaid coverage — fueled by income and job losses during the twin public health and economic crises — are likely to plummet when the federal government declares an end to the pandemic-related public health emergency, according to a recent report from Georgetown University researchers.
When that time comes, possibly as soon as July, states will be required to restart annual renewals for everyone in their Medicaid programs if they have not been able to verify eligibility — an enormous administrative undertaking that could lead to millions of children losing coverage for some period of time, said Joan Alker, executive director of the Center for Children and Families at Georgetown University.
“The data is clear, being uninsured is bad for children’s health,” said Alker, a co-author of the Georgetown report on Medicaid and children’s coverage.
Before the pandemic, states regularly reviewed enrollees’ eligibility for Medicaid based on income and sometimes disability status. But when states stopped removing people from Medicaid during the pandemic, enrollment in the public health insurance program spiked.
Florida will be on ‘high end of coverage losses’
In Florida, more than 1.34 million people have gained Medicaid coverage since March 2020, including about 450,000 children ages 0 to 18 years old, according to state enrollment data. As of January, more than 5.1 million people were enrolled in Florida Medicaid — a record high, and an increase of 36% over total enrollment in March 2020.
Alker and Tricia Brooks, a Georgetown University research professor and co-author of the report, estimate that as many as 6.7 million children with Medicaid in the United States are at risk of losing coverage. The national estimate is based on an assumption that 18% of kids will lose coverage during the re-enrollment review process that all states will undertake.
The report does not provide a state-by-state estimate of children at risk of losing Medicaid, but Alker said the 18% assumption is based on prior Medicaid disenrollment rates following periodic eligibility reviews. She called it “a conservative estimate.”
“Depending on the state,” Alker said, “it could be a lot higher or lower. ... In the case of Florida I am extremely concerned that the state will be on the high end of coverage losses.”
Brooks said states can start to take steps now to ensure that eligible children do not fall through the cracks and lose health insurance coverage when the time comes for the mass eligibility review, also known as the “Medicaid unwinding.”
She urged states to begin confirming eligibility for enrollees now to avoid a backlog later, work with Medicaid managed care plans to update information on covered members, and reach out to all Medicaid recipients with information about the upcoming review.
And she advised states to watch for red flags in the process, such as rising call center volumes and wait times at state Medicaid agencies and managed care plans, or large numbers of people losing coverage due to procedural reasons, such as not replying to a renewal letter.
“States should be prepared to slow down ... or even hit the pause button,” Brooks said, “and take time to review and refine their plan and state processes to avoid large numbers of children along with their parents from becoming uninsured.”
Florida has high number of kids at risk
Alker and Brooks identified Florida as one of six states where kids are especially at risk of losing Medicaid during the unwinding because of public policies that do not make it easier for people to enroll in or retain coverage, such as not having a 12-month continuous eligibility determination and charging premiums or annual enrollment fees. The five other states where children are especially at risk of losing coverage during the Medicaid unwinding are Delaware, Georgia, Missouri, Nevada and Texas.
Without the public health emergency’s continuous coverage requirement, Medicaid eligibility for low-income parents in Florida ends when they no longer have a dependent child. Pregnant women, who can qualify with a higher income than other adults who are not pregnant, can lose Medicaid coverage 60 days after delivery, though Florida has applied to the federal government for approval to extend coverage for new mothers to 12 months.
In addition, because Florida is one of 12 states that has not expanded eligibility for Medicaid to cover low-income, single adults as prescribed under the Affordable Care Act, Florida’s Medicaid program has a high proportion of children, Alker said.
“That is why, particularly in those states that are non-expansion states, the unwinding of the public health emergency is mostly going to impact children,” she said.
Florida’s Agency for Health Care Administration, which manages the state’s Medicaid program, referred questions about preparations for the unwinding to the Department of Children and Families, which makes eligibility determinations for Medicaid. DCF did not immediately respond to questions.
The federal government has renewed the public health emergency for COVID-19 every 90 days since the first one was declared on Jan. 31, 2020. The Biden administration has suggested that states will receive 60 days’ notice before the end of the emergency period in order to prepare, and Alker believes that could happen as early as mid-July.
Florida restrictions on Medicaid
Florida has one of the most restrictive eligibility requirements for Medicaid, which is funded jointly by the state and federal governments. An adult must be pregnant or have a dependent child or a disability to qualify for Medicaid in Florida, and then they must meet income limits.
Adults with dependent children can earn no more than 32% of the federal poverty level, or about $7,000 a year for a family of three, to qualify for Medicaid in Florida. Income limits are higher for pregnant women, who can qualify if their annual household income does not exceed $29,000 before taxes for a family of three.
But children in Florida can qualify for Medicaid even if their parents do not as long as the household’s income is below $44,000 a year before taxes for a family of three (or $35,000 a year for a family of two). Adults without a disability or a dependent child are not eligible for Medicaid in Florida, regardless of income.
Like other states, Florida agreed not to remove anyone from Medicaid during the public health emergency under a provision in the Families First Coronavirus Response Act of March 2020, which required states to keep children and adults continuously covered by Medicaid for as long as the public health emergency declared by the Secretary of the U.S. Department of Health and Human Services remains in effect.
In exchange for not removing people from their Medicaid rolls, states received a raise from the federal government’s matching rate that helps to fund their programs. Florida’s federal match rate for the Medicaid program increased in 2020 from about 62% to 68%, which means that for every dollar the state spends to fund Medicaid, the federal government matches at a rate of $2.
Job losses led to more on Medicaid
The growth in Medicaid enrollment is largely the result of income and job losses during the pandemic, said Alison Yager, executive director of the Florida Health Justice Project, a nonprofit group that advocates for health insurance coverage.
“With so many people losing income entirely, in all likelihood some significant portion of the growth is parents who do now meet Florida’s extremely low-income guidelines,” Yager said.
In many of those families, Yager said, a parent may have found a new job and no longer qualifies for Medicaid under Florida’s guidelines but retained their coverage because of the public health emergency.
When the parent loses Medicaid because they make too much money, Yager said, Florida agencies should connect that person with other coverage options, either through the ACA health insurance marketplace, also known as Obamacare, or through Florida’s KidCare plan for children.
Yager also urged Medicaid recipients to update their home address and other information with the state’s DCF agency to ensure that they receive notices about their coverage.
