[Millions of Americans lost their coverage earlier this year when
a pandemic-era policy expired. The consequences are detrimental to the
very practice of medicine.]
[[link removed]]

THE GREAT MEDICAID UNWINDING  
[[link removed]]


 

Adam Gaffney
October 6, 2023
The Nation
[[link removed]]

*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

_ Millions of Americans lost their coverage earlier this year when a
pandemic-era policy expired. The consequences are detrimental to the
very practice of medicine. _

Participants hold signs during the Senate Democrats’ rally against
Medicaid cuts in front of the US Capitol in June 2017., Bill Clark /
CQ Roll Call via AP Images

 

Ronald Reagan’s ascent to the presidency delivered a swift kick to
the nation’s poor—especially those who had the misfortune to get
sick. His administration’s 1981 budget imposed deep cuts
[[link removed]] on
Medicaid, adding to financial pressures on states to narrow
eligibility and punting some 600,000 beneficiaries
[[link removed]] out of
the program early in the decade. A 1983 study
[[link removed]] in _The
New England Journal of Medicine_ examined the health consequences of
Medicaid cuts in California, where coverage was eliminated for 270,000
people. One study subject who lost coverage died of a brain bleed (she
couldn’t afford the blood pressure-lowering medications that might
have prevented it), another of a stomach ulcer (he spit up blood for
10 days before seeking care, fearing ER bills), and a third of a
probable heart attack (he ran out of heart medications which he
couldn’t afford to refill). This episode is of more than historic
interest: We are now about six months into our own version of what
experts are calling a great “Medicaid unwinding
[[link removed]].”

In April, the pandemic-era “continuous coverage provision”—which
compelled states to keep Medicaid beneficiaries continuously insured
for the duration of the Covid-19 public health emergency, greatly
boosting enrollment—expired. This has already led to the
disenrollment of nearly 8 million beneficiaries
[[link removed]] from
the program, with predictable results. For example, Patricia Jones, a
62-year old West Virginia woman with heart problems and a recent
bloodstream infection, was recently dropped from Medicaid because the
$1,765 a month she was getting in disability survivor’s benefits
after her husband died in March was $149 too high to qualify, _The
Washington Post _recently reported
[[link removed]].
(She has yet to find alternative coverage.) Experts predict that as
many as 24 million enrollees
[[link removed]] might
lose their coverage by the time the unwinding is done.

These giant numbers dwarf the coverage losses of the early 1980s, and
widespread harm is sure to follow. But the so-called “Medicaid
unwinding” isn’t as new as it may seem. Before the pandemic, large
numbers of people lost Medicaid coverage every year, thanks to
shifting eligibility at the margins and administrative snafus. This
feature—inherent to many means-tested programs—has always
compromised coverage and caused suffering for those who depend on this
critical program. Such discontinuities in coverage are all too common
in the fragmented American insurance system, and they undermine the
very essence of what medical care can do.

Ipractice ICU medicine in Massachusetts, a state where only 2.5
percent
[[link removed]] of
residents are uninsured—and which might hence be counted as the
ultimate American health coverage success story. I no doubt see less
medical deprivation than my colleagues in states like Texas, where the
uninsured rate hovers around 18 percent
[[link removed]].
Still, I see how discontinuities in coverage entrenched by a patchwork
system affect my patients’ lives. Those gaps can precipitate
potentially deadly ruptures of care. Inability to fill an insulin
prescription because of a lapse or change in coverage, for instance,
can provoke acute, even life-threatening diabetic emergencies
[[link removed]] that
land a patient in the ICU.

Even when coverage interruptions aren’t acutely life-threatening,
they invariably detach patients from the healthcare system and erode
the ongoing mutual project that ought to be the bedrock of effective
medical care. Most of the benefits of modern healthcare, after all,
emerge not from emergency care provided in places like ERs or ICUs, as
important as that is. Rather, health is protected through
long-standing therapeutic relationships between patients and primary
care physicians that allow medical problems to be recognized and
chronic problems carefully managed. Patients with untreated high blood
pressure who are excluded from such care, for instance, may experience
a slow and silent deterioration of their kidney and heart
function—until the day fluid fills their lungs and they wind up in
an ICU seeing someone like me. Ongoing relationships with trusted
primary care providers can likewise help assure many of the
safety—or the urgency—of interventions like Covid-19 vaccination.
Those excluded may pay the price, winding up with severe,
life-threatening Covid pneumonia in the ICU.

Numerous studies bear this out. One study
[[link removed]], for
instance, found that about a quarter of low-income individuals
experience coverage disruptions over the course of a year; individuals
with such interruptions in coverage are more likely to have to change
doctors or prescriptions, to skip doses of their medications, to go
the ER, or to report worse health compared to those with continuous
coverage. Even though the Covid-19 vaccines were free, colleagues and
I found that health coverage
[[link removed]] and access
to care
[[link removed]] are
associated with higher booster uptake. Another of our studies
[[link removed]] identified a
sharp rise in hospitalizations for diabetic emergencies when teens
became young adults in the US—a time of frequent coverage
disruptions—but not in Canada, where insurance is universal and
seamless across the life course.

Other work highlights the critical importance of a relationship with a
primary care physician—precluded by lapses or even changes in
coverage. A clinical trial
[[link removed]] published
decades ago found that older veterans who were randomized to
“continuous” primary care (i.e., seeing the same provider
regularly) spent fewer days in the hospital and the ICU than those who
were randomized to discontinuous care. This year,
a quasi-experimental
[[link removed]] study
found that when Medicare beneficiaries lose their primary care
physician, they experience a 3 percent increase in hospital admissions
and a jaw-dropping 4 percent increase in mortality. Medical care that
is disjointed and discontinuous, that is to say, may not amount to
care at all.

Since its inception, Medicaid has been on the front lines of the
battle for an American welfare state. In 1964, Democrats swept the
midterm elections, giving them the congressional majorities they
needed to finally realize long-fought-for healthcare reform. The
following year, President Lyndon Johnson signed both Medicare and
Medicaid into law. Medicare was designed in the universal social
insurance mold: It provided something of a national statuary right to
healthcare for almost all older Americans. Medicaid, in contrast,
entered the world as a means-tested program, partially funded (and
controlled) by states, with eligibility initially generally confined
to the so-called “categorically needy”—individuals who were not
merely poor but who also participated in certain welfare programs.
While Medicaid’s out-of-pocket payments are generally low or even
zero, the program provides access to a narrower scope of providers
compared to traditional Medicare. Medicaid is also subject to the
whims and prejudices of state lawmakers, who have significant latitude
to cut eligibility criteria or benefits, sometimes cruelly
[[link removed]]. Still, since its
inception, Medicaid program has greatly expanded, and
improved—particularly as a result of the President Barack Obama’s
Affordable Care Act, which was designed to make all low-income
individuals eligible.

The expansion of Medicaid has had large, extensively documented
benefits: it improves access to healthcare services and health itself,
and, indeed, has saved numerous lives
[[link removed]].
Still, the much-needed rise in participation achieved by the
continuous coverage provision—enrollment rose
[[link removed]] from
71 million to 94 million from January 2020 to April 2023—was at the
same time a testament to how much “churn,” or movement in-and-out
of the program, occurs outside plague years when such protections are
not in play. Small increases in family income can render someone
ineligible for Medicaid. Moving states can provoke disenrollment.
There are sometimes burdensome administrative hurdles
[[link removed].] to
enrollment, which can be particularly challenging for workers with
unsteady employment or income or otherwise tenuous life circumstances.
Annual eligibility redeterminations can result in disenrollment if
forms are not properly completed, or when they are sent by state
agencies to the wrong address.

A string of news stories before the pandemic revealed how common such
disenrollment normally is, at least in many states. In 2018, some
70,000 people, mostly children, were dropped from Missouri’s
Medicaid program, mostly “because they failed to reply to a mailed
renewal form,” according
[[link removed]] to _NPR_.
A 2019 story
[[link removed]] in _The
Texas Tribune_ described how the state used an automated system to
check family income multiple times a year to validate children’s
ongoing eligibility, which caused thousands of children to lose
coverage every month, sometimes in error. The same year, _The
Tennessean _reported
[[link removed]] that
120,000 had been dropped from Tennessee’s Medicaid program since
2017: “Nearly all of these disenrollments occurred when the state
government processed insurance renewals with an outdated system of
paper forms and postal mail,” the paper noted. Similarly, in Idaho,
a large number of children were dropped from Medicaid in the years
before the pandemic thanks to a more onerous state enrollment system
that was at least in part driven by guidance from the Trump
administration, _ProPublica _found
[[link removed]].
None of these are aberrations: one recent study
[[link removed]] found that
Medicaid participants have a roughly 20 percent chance of having a
lapse in coverage over a given two-year period.

Just how many victims of today’s “Medicaid unwinding” will find
alternate coverage and how many will remain uninsured isn’t yet
clear. But there’s little doubt that many will be harmed. Research
has found that Medicaid expansion
[[link removed]] saves
lives; it is a reasonable extrapolation of these findings to say that
contraction will take some.

The continuous coverage provision should be seen as two things at
once: a successful example of what action born of an emergency can
achieve, but also an indictment of the pre-pandemic status quo.
Uniquely among high-income nations, we allow our residents to
periodically, and protractedly, lose healthcare, and to suffer as a
result. Achieving the goal of universal coverage is a moral
imperative. Yet any vision of universal healthcare worthy of the name
must provide seamless, cradle-to-grave healthcare to everyone. Without
continuity, there is, far too often, no care at all.

_Copyright c 2023 The Nation. Reprinted with permission. May not be
reprinted without permission
[[link removed]].
Distributed by PARS International Corp
[[link removed]]._

_ADAM GAFFNEY is a critical care physician and an assistant professor
at Harvard Medical School._

_Please support  progressive journalism. Get a digital subscription
[[link removed]] to THE
NATION for just $24.95!    _

_THE NATION [[link removed]] Founded by abolitionists in
1865, The Nation has chronicled the breadth and depth of political
and cultural life, from the debut of the telegraph to the rise of
Twitter, serving as a critical, independent, and progressive voice in
American journalism._

* Medicaid
[[link removed]]
* health-care coverage
[[link removed]]

*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

 

 

 

INTERPRET THE WORLD AND CHANGE IT

 

 

Submit via web
[[link removed]]

Submit via email
Frequently asked questions
[[link removed]]

Manage subscription
[[link removed]]

Visit xxxxxx.org
[[link removed]]

Twitter [[link removed]]

Facebook [[link removed]]

 




[link removed]

To unsubscribe, click the following link:
[link removed]