As states continue to monitor, manage and discuss the impacts of the unwinding of the Medicaid continuous coverage requirement on (combined) millions of patients currently receiving Medicaid, I’m reminded of what we saw happen during the advent of the Affordable Care Act (ACA) in 2010. In an effort to improve access to care for uninsured, low-income Americans, the ACA allowed states to expand Medicaid eligibility to more people who previously didn’t qualify: adults without dependent children, individuals with pre-existing conditions, and those with incomes up to 138% of the Federal Poverty Level. Over the course of the next decade, three-quarters of states would opt to expand coverage and would see accelerated enrollment rates as a result.
At the beginning of 2024, 40 states and Washington, D.C. had expanded Medicaid, significantly lowering the rates of uninsured patients. According to the latest data from the U.S. Treasury, have signed up for health insurance coverage through ACA marketplaces. But just as hundreds of thousands of patients gained that expanded coverage overnight, they’re now losing that coverage almost as quickly. Studies have consistently shown that Medicaid expansion increased healthcare coverage, access, and utilization among low-income Americans, but as unwinding Medicaid coverage continues, the economic, financial, and health impacts previously felt by expansion states may be partially undone. Let’s take a walk through history, looking at the benefits of Medicaid expansion, the impacts of Medicaid unwinding, and at how states can best continue to care for their populations receiving Medicaid.
Improved health measures
It should come as no surprise that the first item on the list of the benefits of Medicaid expansion is improved health outcomes. States that expanded Medicaid consistently saw better outcomes for measures like blood pressure and glucose control, particularly for Black and Latinx patients. Communities in expansion states also saw an increase in viral suppression among patients with HIV – which is a vital part of improving clinical outcomes while also reducing transmission – and yet another study found that Medicaid expansion was linked to a reduction in low birth weights and preterm births.
Now, with Medicaid unwinding, there’s a risk of undoing some of the good that Medicaid expansion created. A study published in early 2024 found that almost 17% of young adults, BIPOC patients, and those with HIV/AIDS were disenrolled from Medicaid and went without coverage for at least six months. That study also found that, even among those who were able to find another source of health insurance, there were significant gaps in their coverage as they made the change. Additionally, those who were disenrolled reported almost doubled costs of care versus those who remained enrolled.
What is particularly unjust is data and reportsabound to reveal much of the disenrollment has been for “procedural reasons,” not because the patient was deemed ineligible. Patients may be disenrolled because they don’t receive renewal notices or can’t complete the redetermination process, or simply because eligibility workers aren’t able to process documents before a case is automatically closed.
Net positive economic impacts
Despite what many against ACA expansion said, the fiscal impact on states was a net positive. States that expanded Medicaid saw a lower increase in state spending per enrollee than states that opted not to expand Medicaid. Additionally, studies found there were no significant changes in employment rates of, or hours worked by, low-income adults between states that expanded Medicaid and states that didn’t, despite arguments that expansion states would see a drop in both factors. In fact, Medicaid expansion has also been associated with an increase in these populations’ probability of being employed and working more hours weekly.
Overall, the “fiscal multiplier” from Medicaid expansion was >1 during the Great Recession, meaning the increase in spending resulted in even more economic stimulus and benefit to the economy, which outweighed the costs of expansion. Simply put: Having healthier people in the workforce means more productivity and consumer spending during recessionary periods.
Benefits for rural areas
Finally, Medicaid expansion under the ACA ensured that rural hospitals and clinics had access to new funding resources. As a result, they could afford to expand their services and hire more staff, meaning that patients going without regular care could now afford to see a doctor. As Medicaid unwinding involves the re-evaluation of who is eligible for Medicaid, states with large rural populations are seeing the largest drops in coverage – meaning more rising risk patients will be unable to access the care they were previously able to, and the odds of them becoming high-cost claimants will only rise.
State-based solutions for ongoing patient coverage
Current estimates indicate that a substantial portion of those losing coverage due to Medicaid unwinding are the same patients who benefited from ACA expansion. As we continue to monitor the impacts, there are measures policymakers, state agencies and health plans can – and must – begin implementing to ensure patients don’t feel the impacts of this unwinding.
Policymakers can advocate for increased budget and staffing to ensure the Special Enrollment Period is leveraged to the fullest extent. State agencies, in turn, would then be able to direct additional resources toward contacting patients identified as eligible to receive Medicaid, but who have lost coverage. Those actively reaching out to patients should prioritize multiple channels for outreach – including coordination with their providers – to reach out to the patients who have yet to reenroll, or who have been automatically disenrolled due to “procedural reasons.
State agencies and health plans should also prioritize the implementation of communication sequencing – using multiple direct touch points to inform patients of their healthcare coverage options – to reach patients who have, or might, lose coverage. Those responsible for heading up these communication sequences should be equipped to help these patients check and see if they still qualify for Medicaid coverage – which, for health plans, could mean equipping providers to do so or engaging with community health workers, social workers, and community organizations for support.
As these sequencing campaigns are planned, state agencies can leverage the mandate that they determine potential eligibility for other insurance affordability programs to implement a re-enrollment campaign that will aid with procedural denials. At Waymark, our care team members are equipped to do this for patients who lose Medicaid coverage due to unwinding, income changes, or other such factors; they help patients see what insurance options are now available to them and partner with them as they make the transition. The most vital element is that the patient does not experience any coverage gaps.
In my view, the positive impact of ACA expansion – which is backed by data – is undeniable. Thanks to the increased numbers of patients receiving Medicaid nationwide, there have been better health outcomes for patients, positive financial and medical resources for rural populations who before weren’t able to seek medical care until an emergency occurred, and an uptick in employment rates that in turn boosts the economy. As Medicaid unwinding continues and our nation moves toward another chapter in Medicaid’s ongoing story, I encourage policymakers, state agencies and health plans to adopt some of the methods suggested above to ensure that those eligible to receive Medicaid continue to be able to do so – and, thus, have access to equitable, affordable healthcare.
Sections of this blog post are paraphrased from chapters 3 and 6 of Sanjay Basu’s upcoming book, “Transforming Medicaid: A Blueprint for Equitable Care.” Scroll to the footer and enter your email to receive an update when a free digital download of the book is available.
