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Florida’s Medicaid Unwinding Lacks Fundamental Safeguards And Can Harm Population Health

A wide shot of a Florida state flag billowing against a clear blue sky.

The process of unwinding Medicaid’s continuous enrollment guarantee, a special emergency public health protection for vulnerable Americans enacted early in the COVID-19 pandemic, is now in its eighth month. Between April and November 2023, more than 11 million Medicaid beneficiaries have been disenrolled; millions more will lose coverage in the coming months. The purpose of the special continuous enrollment guarantee was to ensure that people would retain insurance during a pandemic characterized by its highly communicable nature and its severe impact on health. Over the continuous enrollment guarantee period, Medicaid enrollment grew from 64 million in February 2020 to about 86 million by January 2023.

Legislation requiring states to unwind—that is, restore normal Medicaid eligibility redetermination procedures—gives states the flexibility to move faster or slower and with greater or fewer safeguards for protecting against erroneous eligibility terminations. But two particular safeguards are not simply a matter of state flexibility; they are instead grounded in the US Constitution’s due process guarantee, as set forth by the United States Supreme Court in its 1970 landmark decision in Goldberg v Kelly. These special Constitutional rules apply to government assistance programs based on what the Court recognized was the “brutal need” of deeply impoverished people. First, before taking action against any particular individual, public officials must send advance notice that explains their actions clearly, the factual basis for those actions, and their reasoning as to why benefits should terminate for that individual. Second, officials must offer people facing loss of benefits the right to an administrative hearing before an impartial administrative officer; if people request such a hearing in a timely fashion (they typically have about 10 days to do so), then officials may take no further action until the matter has been decided following an evidentiary review.

Assuring Constitutional due process safeguards is a duty of all Medicaid agencies. Congress explicitly referenced these due process safeguards in its winddown legislation, as did the Centers for Medicare and Medicaid Services (CMS) in its winddown guidance. Unwinding continuous enrollment is an unprecedented undertaking given the sheer size of the enrolled population, the underlying complexity of Medicaid eligibility, and the challenges of both reviewing all existing cases while also continuing to accept new applications. But the bipartisan consensus regarding the need to observe basic due process protections underscores how fundamental Medicaid is to health care access and the stakes involved as tens of millions of children and adults face a threat of coverage loss. 

Careful individualized consideration when reviewing eligibility is especially important in the case of Medicaid, given its complexity. In a single household, one can find family members each receiving Medicaid based on completely different eligibility criteria. Take a family with a mother, a child, and a grandparent, all three of whom are enrolled in Medicaid but on completely different grounds, using three different sets of applicable financial eligibility rules. The mother might be insured as a low-income working-age adult or as a poor parent or on the basis of extended postpartum coverage, or because of her status as an adult with a severe disability. The child may qualify as a low-income child or a child with a disability. The grandparent likewise could be covered as a low-income elderly person, as a disabled person or even as a low-income working-age adult. During unwinding, agencies must separately review eligibility of each household member, and each must be notified of the agency’s decision and given the opportunity to appeal if the decision is to terminate coverage. (States’ failure to conduct individualized determinations for children emerged as a major issue by the summer, when large numbers of children were improperly terminated). 

The unique nature of the continuous enrollment protection also underscores the need for procedural safeguards to protect against wrongful coverage terminations. Many people who enrolled in Medicaid during the pandemic likely gained coverage for the first time and have no experience with the redetermination process. This requires an approach that utilizes a long and sufficient time for both the Medicaid agency and the beneficiaries to carefully communicate eligibility information to avoid improper terminations or terminations that happen for purely procedural reasons arising from beneficiaries’ inability to navigate the complicated renewal system. The Affordable Care Act streamlined enrollment and renewal in important ways in order to ensure that, before states seek information from beneficiaries, they gather all available and relevant information and perform the renewal ex parte and without the need for beneficiary involvement. Even with these reforms, HHS researchers estimated that almost half of the approximately 15 million people who could lose Medicaid during unwinding would be terminated for procedural grounds owing to the paperwork difficulties of the renewal process itself, not because they were actually ineligible. 

This advance knowledge regarding the complexity of unwinding and the potential for large numbers of procedural losses warrant even greater care in the process, especially because the types of procedural problems beneficiaries face are well-documented. Many fail to submit information sought by states when the ex parte system fails, either because they don’t receive the notice or because they have encountered insurmountable paperwork barriers. State renewal systems may have lain dormant during the pandemic, and agencies often lacked current addresses. These problems are compounded because states may make errors in their determinations, fail to offer sufficient resources to help beneficiaries or do not offer clear notices to beneficiaries, including their rights to appeals. The sheer volume of cases that must be reviewed, coupled with the complexity of Medicaid eligibility rules, staff shortages, and worker turnover, means that mistakes are inevitable. People whose primary language is not English can face especially high barriers. For example, in Florida, Spanish-speaking recipients had to wait hours to speak to a Spanish-speaking agent. Given the potential for navigation problems, providing people with clear notice when coverage is set to end, and offering a clear appeals process, becomes even more of an imperative.

In August 2023, Florida became the first state to face litigation over its unwinding process. In their lawsuit, the plaintiffs seek to represent the entire class of beneficiaries losing coverage as a result of a breakdown in the state’s renewal process that deprived them of timely and adequate notice and an opportunity for a pre-termination hearing. They lay out in detail the state agency’s failure ensure that beneficiaries receive clear and accessible information; plaintiffs have filed with the court extensive evidence showing the actual notices received, which are frequently incomprehensible even to people who can read English at an advanced educational level.

Assessing The Health Implications Of Florida’s Unwinding

This report discusses some of the likely population health effects of Florida’s unwinding on people losing coverage, based on data from the first several months of unwinding. Drawing on data reported through September 2023, Florida completed Medicaid eligibility redeterminations for about 2.552 million beneficiaries, renewing coverage for 1.729 million but terminating coverage for 823 thousand, roughly one-third. Of these, 435 thousand (a majority) were considered ineligible for procedural reasons, not because they were actually ineligible. Thousands more cases were still undergoing redetermination.

We estimate the number of people who will be terminated from Florida’s Medicaid program due to procedural problems and their characteristics, based on these initial months of experience. The Urban Institute’s health policy simulation model indicates that almost one-third (32 percent) of those losing Medicaid in Florida will become uninsured. 

Some children terminated from Medicaid may be able to gain coverage under the Children’s Health Insurance Program. Others may be able to get insurance coverage (Qualified Health Plans) through the federally supported Health Insurance Marketplaces (healthcare.gov in Florida). More generous subsidies, initially provided under the American Rescue Plan and then extended through 2025 by the Inflation Reduction Act, help low- and moderate-income people purchase Qualified Health Plans. Unfortunately, many who lose Medicaid coverage because of procedural problems cannot be routinely referred to healthcare.gov for enrollment because there is not sufficient information available about them. Moreover, those with incomes below the poverty line who lose Medicaid are not eligible for the Health Insurance Marketplace and are unlikely to have job-based health insurance coverage.

Many may get private insurance coverage from an employer or union, but may still be unable to afford care because of the deductibles, cost-sharing requirements and other limits that are common in private health insurance. In comparison, Medicaid has very low, nominal cost-sharing requirements. While seniors 65 or older may lose Medicaid in the redetermination process, almost none become uninsured because of Medicare’s near universal coverage. However, Medicare recipients losing Medicaid may find health care less affordable due to Medicare’s higher cost-sharing and because they lose Medicaid benefits not covered by Medicare such as vision, dental, and long-term care.

However, those who lose Medicaid because of procedural problems and become uninsured can face health problems. Data from recent health surveys shed light about the characteristics and health problems of those who lose Medicaid in Florida because of procedural difficulties.

Behavioral Risk Factor Surveillance System (BRFSS) data for 2022 indicate that publicly insured Floridians 18 to 64 years old had the following characteristics:

  • 62% are female;

  • 38% are Latino, 35% are White non-Hispanic, 19% are Black non-Hispanic, and 8% are other or multi-race;

  • 49% have had a serious chronic health problem, such as diabetes, heart attack, stroke, coronary heart disease, chronic obstructive pulmonary disease, emphysema, kidney disease, arthritis, asthma, blind or deaf;

  • 2% are pregnant women;

  • 25% have experienced serious depression.

National Survey of Children’s Health data from 2020-21 reveal that Florida children (under 18) with public coverage are:

  • 51% female;

  • 34% Latino, 31% White non-Hispanic, 28% Black non-Hispanic, and 5% other or multi-race;

  • 42% have chronic health conditions, such as diabetes, asthma, autism, cerebral palsy, attention deficit disorder, cystic fibrosis, various genetic diseases or depression;

  • 16% have serious emotional problems, including depression, anxiety, behavioral conduct problems.

And even if children do not have current health problems, they may need preventive care, such as vaccinations, dental care or health monitoring, such as that provided under Medicaid’s Early and Periodic Screening Diagnosis and Treatment (EPSDT) component.

Over the course of one year, the 5.8 million Floridians enrolled in Medicaid as of April 2023 will need to have their eligibility redetermined. If 17.0 percent of them are found ineligible for procedural reasons, as has occurred in the first few months, then about 984,000 will lose Medicaid for procedural reasons after the first year, including about 266,000 children, 532,000 non-elderly adults and 187,000 seniors (although most seniors will retain Medicare). Combining the Urban Institute’s estimate that 32 percent of those losing Medicaid become uninsured with data from BRFSS and NSCH, we can estimate characteristics of Floridians who become uninsured due to procedural terminations during the Medicaid unwinding after one year (see exhibit 1).

Exhibit 1. Estimated number of Florida adults and children becoming uninsured due to procedural problems after one year

Source: Authors’ calculations, using BRFSS and NSCH data, cited above.

The estimated number of Floridians who could lose Medicaid coverage and become uninsured for procedural problems (266,000) is greater than the entire population of St. Petersburg, Florida and includes over 100,000 women and 80,000 children. 

The harm will fall disproportionately on Latino (92,300) and Black Floridians (56,800) but also heavily on Whites (83,300). This would deepen racial inequities in health care access. Perhaps of greatest concern, almost half of those becoming uninsured (118,500 adults and children) could have serious, chronic health problems like diabetes, cardiovascular disease, asthma, autism, cerebral palsy or other diseases that require ongoing medical care and medications. Without health insurance coverage, these low-income Floridians could lose access to care and become sicker. Thousands could end up requiring emergency medical care, hospitalization and even death that could be prevented with access to better health care. Over 12,000 pregnant women could lose access to prenatal care, leading to an increase in adverse outcomes, including miscarriages and low weight births. Finally, over 55,000 adults and children could lose access to mental health care, resulting in greater emotional suffering and behavioral health problems. 

Concluding Thoughts

Florida’s approach to Medicaid redeterminations could lead to serious harm for hundreds of thousands of Floridians. The plaintiffs in the Florida lawsuit include pregnant and postpartum women and children with significant disabilities who had to forgo or incur bills for necessary medical care after losing Medicaid. People who lose coverage for procedural problems are at risk of delaying or forgoing preventive care and/or ongoing care for chronic conditions. This could exacerbate racial/ethnic health disparities and worsen health outcomes. A more careful approach, that maintains their Constitutional rights to clear notification and appeal rights, would reduce the harm to low-income Floridians.

While these data and the current lawsuit pertain to Florida, there are broader implications for other states as well. Of the more than 11 million beneficiaries who have lost Medicaid nationwide as of November 2023, more than 70 percent lost their coverage due to procedural reasons. It is likely that millions of them are, in fact, still eligible for Medicaid but lost coverage because of the insurmountable paperwork barriers. A large proportion of the children and adults who become uninsured as a result of these paperwork problems also have serious health needs, including pregnancy and mental health challenges or require care for chronic health problems like diabetes or heart disease. CMS and the states need to exercise due caution as they continue the Medicaid redetermination process. And we need to bolster the safety net system of community health centers, mental health clinics and safety net hospitals that will have to provide care for more people who have lost their health insurance coverage. CMS, states, and beneficiary advocates will be watching the outcome of the Florida litigation as they consider policy changes to minimize erroneous coverage losses as unwinding continues.

Sponsored Content: UHC

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