A Normal Catastrophe: The Great Medicaid Purge of 2023
Millions of People Lost Health Insurance in 2023. Just Like They Do Every Year.
As 2023 draws to a close, no story better exemplifies the state of American health care than The Great Medicaid Purge of 2023. People had been allowed to keep Medicaid coverage indefinitely during the pandemic, but those protections ended last March and millions of people are losing Medicaid eligibility. The Great Medicaid Purge is a catastrophe for millions of people. It’s also totally normal. It’s been happening right in front of our eyes every month for more than a half century.
At its core, the Purge is easy to understand: federal and state governments saved up up three years of monthly pain to inflict all at the same time.
Medicaid is a government health insurance program for poor people. Governed by federal law but administered by state governments, it is jointly funded. The federal government matches state tax revenue roughly 50/50, although the exact federal matching percentage varies by state.
To get Medicaid coverage for yourself or your kids, you have to prove to the government that you’re poor or disabled. Then at least once a year you have to prove you’re still poor enough to merit coverage. If not, you lose your insurance. If you get a better job or a raise during the year, you have to tell the government. In many states, if your new income crosses the threshold for eligibility, you can lose your coverage at the end of the month.
On March 18, 2020, Congress passed the Families First Coronavirus Response Act (FFRA). The law temporarily increased the amount of federal matching money for Medicaid and required states to stop kicking people who flunk the poverty test off of Medicaid until the Covid-19 Public Health Emergency was over. Known in policy wonk circles as “continuous enrollment”, these provisions drove an increase in Medicaid coverage from 72 million in February 2020 to 94 million in March 2023, according to the Kaiser Family Foundation.
Evidently, the idea of poor people not having to grovel for health care was so abhorrent that Congress, on December 22, 2022, ordered states to start reviewing eligibility and disenrolling people again after March 2023, regardless whether the President declared a formal end to the Public Health Emergency. In April, millions of people started being forced off Medicaid and CHIP. The process is still ongoing.
A November 2 KFF Health News story headlined “Worse than Can be Imagined: Medicaid Unwinding Breeds Chaos in the States” gives a flavor of the Purge. Patients’ care has been disrupted, state administrators are overwhelmed, people trying to find out if they’ve been kicked off are spending hours waiting on hold and paperwork has gotten lost.
This is a disgrace. In a nation as rich as the U.S. that spends far more money on alleged health care than other wealthy nations, there’s no excuse for this level of suffering, confusion and administrative chaos. But at Healing and Stealing, we can’t help also asking, why the fuss?
Medicaid was designed this way. Millions of people face bureaucratic nightmares and the possibility of losing access to their doctors every single month. The decision to begin “unwinding” the pandemic rules was bipartisan, enacted during the waning months of a Congress with both houses ultimately controlled by the Democratic Party.
To really understand the purge, it helps to keep two things about Medicaid that can seem contradictory in your head at the same time:
It is a desperately needed lifeline protecting more than 20% of the U.S. population from illness, injury and death.
It is the worst public health insurance program among the world’s richer countries
Before COVID-19, Medicaid covered a little more than a fifth of the U.S. population. That number rose to more than a quarter under the 2020 law. Medicaid covers a wide array of services with virtually no cost sharing. The closely related Children’s Health Insurance Program (CHIP) also limits cost-sharing, making these two programs theoretically among the best health insurance in the U.S.
Medicaid and CHIP have saved countless lives and eased the suffering of millions of Americans. According to KFF, in 2022, Medicaid covered more than 1.5 million births, or 41% of all children born in the U.S.! It’s difficult to imagine how much worse the U.S.’s wretched infant mortality rates would be in the absence of Medicaid payments for maternal and child health.
Obviously, Healing and Stealing has criticism of Medicaid. But remarking on the value of Medicaid isn’t a straw man set-up for negative comments. It’s deeply personal. At least three of my immediate family members have grasped Medicaid’s lifeline over the years, often in times of serious health crisis.
That said, Medicaid sucks. It’s a degrading, punitive, inefficient mess built on the condescending puritanical fantasies that infect most social policy in the United States. One of the many darkly comic pleasures of writing about U.S. health care is listening to politicians talk about Medicaid as an “entitlement”. As insurance industry front group AARP puts it, entitlements supposedly “provide benefits to everyone meeting the eligibility requirements, regardless of the cost of doing so.”
The truth is, if you tried to create a health insurance program to which people are less “entitled” than Medicaid, you’d have your work cut out for you. People’s eligibility shifts constantly with income, family size and even age. Even if you stay deservingly poor, in many states as your children age they lose Medicaid and/or CHIP because the programs are organized on the idea that infants definitely need to see a doctor but 7-year-olds not so much.
The Kaiser Family Foundation has poured resources into tracking Medicaid and CHIP coverage for decades and doubled down impressively during the pandemic.* Yet Medicaid is so chaotic that KFF’s helpful “10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision” includes this stunning statement:
Uninsurance is dangerous and sometimes fatal. Yet 52 different governments couldn’t narrow down the range of people about to lose eligibility for the health insurance programs they run to less than “between 8 and 24 million.” And this is for an administrative review that has been a normal, everyday process for years.
According to KFF, 13.4 million Americans had been disenrolled from Medicaid as of December 21. One-third of all completed “renewals” resulted in the person getting kicked off. Most of those, 71%, lost coverage not because they were “factually” ineligible, but for “procedural” reasons like the state having the wrong address or missing information on the renewal forms. Many of the millions of people who have gotten the boot may actually still be eligible for Medicaid. States have only reviewed about 40% of the people who were on Medicaid last February and at the current rate of outcomes, disenrollments will exceed KFF’s high-end 24 million projection.
In theory, people losing Medicaid/CHIP coverage have other “options,” either job-based or through the Obamacare exchanges. But there are obstacles to actually getting health care. First of all, you have to know you’ve lost Medicaid - if the state sends information to the wrong address, you may wind up uninsured and not even know it. For those with suddenly higher income, “Affordable” Care Act coverage often isn’t. Same with job-based coverage. Even when people can afford the premiums, low cost insurance often carries heavy deductibles, coinsurance and copays that render it meaningless.
In an interview with Healing and Stealing, Laurel Lucia, director of the Health Care Program at the UC Berkeley Labor Center, said that California has passed laws making a transition to Covered California, the state’s Obamacare exchange easier, but it’s “too early to tell” how many people losing Medicaid in the Purge have or will ultimately get other health insurance coverage. As of September, enrollment through the exchanges had increased by just 1.5 million from September 2022.
KFF data suggest that 4.8 million new people have enrolled in Medicaid since the Purge began.** Their coverage offers a temporary opportunity to get needed health care without fear of medical debt or agonizing choices between seeing a doctor and paying the rent or buying food. But each doctor’s visit or drug store trip comes with an axe hanging over each patient’s head. Within a year of the day their insurance started, they’ll have to go through the same process that 94 million Americans going through the Purge have endured.
Some of the problems identified in the press have been made worse by the volume of work that state agency staff face. But all of them are endemic to Medicaid. Millions of people eligible for Medicaid are not enrolled, including between 17% and 20% of the uninsured, according to the Robert Wood Johnson Foundation. This is due significantly to administrative barriers that disproportionately affect people of color and low-wage workers. The Affordable Care Act reduced some of those barriers, but as Berkeley’s Lucia puts it, what we’ve seen in 2023 is a “more concentrated version of what happens in our health care system” every year.
The Great Medicaid Purge of 2023 is a catastrophe, cutting a lifeline to millions of people. And it’s also a totally normal bloodletting by the worst public health insurance program in the world. Happens every month.
A (VERY) LITTLE EXTRA FOR THE DATA CURIOUS
*KFF’s data tracker is more than two months ahead of the Biden Administration and other NGOs like Georgetown University’s Center for Children and Families. On December 18, the Administration released data through September, showing 9.2 million disenrollments. Unlike Georgetown, KFF also makes the underlying data for its graphics easily downloadable. Hats off to KFF.
**According to KFF’s Medicaid unwinding tracker, as of December 21, 13,379,587 completed renewals had resulted in disenrollment, and net Medicaid enrollment had declined by 8,574,809. So: 13,379,587 - 8,574,809 = 4,804,778.