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Quiet Crisis of Medicaid Redeterminations and Disenrollments Demands Attention
It is well known that people with behavioral health conditions can have great difficulty enrolling in health insurance and remaining enrolled. That is why the current enrollment redeterminations mandated for state Medicaid programs are so concerning to the field. Kaiser Family Foundation has estimated that between 8 and 24 million persons could be disenrolled from Medicaid as part of this. Assuming conservatively that overall prevalence rates for behavioral conditions (25% annual prevalence for adults) apply to this group, that would mean between 2 and 6 million persons with behavioral health conditions could be disenrolled in the coming months. These are shocking numbers.
At the outset of the COVID-19 pandemic, the Families First Coronavirus Response Act required that state Medicaid Programs keep people enrolled continuously, and that the federal government would provide states with enhanced federal Medicaid funding to help cover related costs. This resulted in an expansion of the Medicaid population from about 72 million to 95 million enrollees nationally between 2020 and the present. The Consolidated Appropriations Act of 2022 ended this continuous enrollment requirement on March 31, 2023, and initiated a phase down of federal Medicaid matching funds by December 2023.
All states began the mandated redetermination process between February and April this year. Informal reports from the field suggest that as many as 1 million enrollees already have been removed from the rolls. In this process, the state Medicaid agency reviews beneficiary income, household size, and other eligibility criteria using electronic data sources. Sometimes the beneficiary is asked for additional information. Even if the beneficiary still qualifies for Medicaid, it is essential that he or she participate in this redetermination process. If not, the state will disenroll the beneficiary despite being qualified.
It seems clear that certain groups will have greater difficulty in maintaining Medicaid coverage in the redetermination process, including persons with disabilities, such as mental health, substance use, and intellectual and developmental disability conditions, those who are older, those who have changed their physical address, immigrants, and persons with limited English proficiency. Even if they remain eligible, they will be at increased risk of losing coverage or experiencing a coverage gap due to difficulties in negotiating renewal requirements.
Similar issues will occur for these individuals when they are determined to no longer be Medicaid eligible. They will have increased difficulty in applying for health insurance for low-income individuals through the state health insurance marketplaces set up under the Affordable Care Act, or in applying through their employer for work-based health insurance.
Although the Centers for Medicare and Medicaid Services already has issued alerts to Medicaid recipients about this redetermination process, it is truly clear that the behavioral health field will need to provide support and navigation guidance to Medicaid enrollees with behavioral health conditions. Such efforts are needed right now on 2 fronts: to help those who remain eligible for Medicaid to re-enroll and to help those who no longer are eligible for Medicaid to enroll in other public or private health insurance.
We have known for an exceptionally long time that the discontinuous enrollment of beneficiaries in Medicaid (called “churn”) does lead to much greater difficulty in accessing health and behavioral health services. That is why we always have advocated for continuous enrollment on a predictable cycle, e.g., 5 years, with a much longer period for transition when a beneficiary is no longer eligible. These principles clearly are being violated in the current mandatory redetermination process.
Some have called the current redetermination process a “quiet crisis” that is receiving extraordinarily little political or media attention. Despite this, it will be necessary for us to mobilize the field to provide the support and navigation our Medicaid clients need at this time. The need is urgent.
Ron Manderscheid, PhD, is the former president and CEO of NACBHDD and NARMH, as well as an adjunct professor at the Johns Hopkins Bloomberg School of Public Health and the USC School of Social Work.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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