When the U.S. Department of Health and Human Services’ public health emergency for COVID-19 expires—which is expected to occur sometime in 2023—states will resume Medicaid eligibility determinations for the first time in more than two years, putting health insurance coverage at risk for millions of the most vulnerable Americans. Congress can protect low-income people, including postpartum women and young children, from losing insurance coverage and access to vital health services at a modest cost by including a continuous coverage requirement in its year-end legislative package.
The public health emergency temporarily establishes continuous coverage for all
The Families First Coronavirus Response Act’s (FFCRA) Medicaid continuous coverage provision has preserved coverage and averted insurance disruption for millions of Americans during the COVID-19 pandemic. In exchange for enhanced federal matching payments for Medicaid, all 50 states and the District of Columbia are prohibited from involuntarily disenrolling Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries from March 2020 until the end of the month in which the federal COVID-19 public health emergency expires. As a result, enrollment in Medicaid and CHIP has grown to 82 million as of July 2022, with children accounting for 42 percent of new enrollment growth, and the nationwide uninsured rate reached a historic low of 8 percent in the first quarter of 2022.
Among the millions who currently have Medicaid or CHIP coverage, an estimated 41 million are children, more than 9 million of whom are covered by CHIP. This program, which offers coverage for children and pregnant women in lower-income households ineligible for Medicaid services, is provided in conjunction with Medicaid in at least 40 states. With the expiration of the FFCRA continuous coverage requirement, however, it also faces enrollment changes.
Medicaid/CHIP enrollees could at least temporarily lose coverage without the continuous coverage requirement
Upon the conclusion of the federal continuous coverage requirement, states will resume Medicaid eligibility redeterminations, and adults and children who no longer qualify for Medicaid or CHIP coverage will be disenrolled over the following 14 months. Even for those who may still be eligible, significant administrative burdens to eligibility renewals mean that between 5 and 14 million individuals could at least temporarily lose coverage, subjecting them to insurance churn and disrupting economic security and access to critical health services.
Continuous coverage is especially important for pregnant women and children
Prenatal care, birth supports, and postpartum care are critical for supporting healthy deliveries and early child development. The United States has long lagged behind other developed countries in its rates of maternal mortality (23.8 deaths per 100,000 live births), with the rate being exceptionally high for Black women (55.3 per 1,000). Likewise, infant mortality rates in the United States (5.8 deaths per 1,000 live births) are well above those of Organization for Economic Cooperation and Development (OECD) countries (3.8 per 1,000). This is true even among top-ranked U.S. states, and the disparities are particularly stark among communities of color.
As the single-largest provider of perinatal care, Medicaid finances nearly half of all births nationwide. Federal statute requires that states provide Medicaid coverage for pregnancy-related health expenses for 60 days after giving birth. Because the FFCRA barred states’ disenrollment of eligible individuals, pregnant women have, in effect, had continuous coverage for 12 months postpartum throughout the pandemic—a practice otherwise only adopted by about half of states. During the pandemic, continuous coverage has been a lifeline to thousands of pregnant women and postpartum mothers and has been particularly important in nonexpansion states, including Texas, Florida, and Georgia. With more than 3.6 million births in 2021 alone, approximately 1.5 million of which were financed by Medicaid, the impact of expanded and continuous coverage cannot be overstated.
With more than 3.6 million births in 2021 alone, approximately 1.5 million of which were financed by Medicaid, the impact of expanded and continuous coverage cannot be overstated.
Lack of insurance coverage is associated with higher mortality rates, particularly during pregnancy. Even for pregnant women who gain Medicaid coverage, disruptions to coverage 60 days after birth often result in inadequate or no postpartum care, increasing the risk of maternal and infant mortality and morbidity. Expanded Medicaid coverage for adults is also associated with significant declines in infant mortality. Yet the public health emergency’s continuous coverage rules have ensured that pregnant women and young children do not face disruptions to coverage, improving their outcomes by reducing birth complications, providing mental health support services, and boosting access to family planning services, including breastfeeding support for mothers who choose that option.
Children whose parents have continuous coverage also benefit directly from improved access to health care services and the increased family financial security afforded by lowered health expenses. The Center on Budget and Policy Priorities reported that children whose parents were enrolled in Medicaid saw a nearly 30 percent increase in their likelihood of receiving critical early care, such as well-child visits. These kinds of preventive health services both support child development and family economic well-being and promote a range of later outcomes, such as better health in adulthood, greater school readiness, and higher adult earnings.
While continuous coverage is beneficial for all enrollees, it is particularly beneficial for communities of color. Medicaid accounts for more than 60 percent of births among Black, Hispanic, American Indian and Alaska Native, and Native Hawaiian and Pacific Islander mothers—compared with 30 percent of births among white mothers—and these communities also experience higher rates of infant and maternal mortality, in addition to higher rates of low birth weight, preterm births, and births following little to no prenatal care. Notably, birth outcomes bear significant influence on early health and developmental outcomes, with long-standing health inequities driving worse maternal and infant health among communities of color. Continuous coverage is a critical lever for mitigating those inequities and improving access to care.
Congress should act now to guarantee continuous coverage to pregnant women and kids in all states
The U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation has estimated that 5.3 million children will face Medicaid/CHIP disenrollment when the public health emergency expires. States are taking a variety of approaches to prepare for the unwinding of Medicaid continuous coverage protection. For instance, to improve coverage for children, states such as Washington, New Mexico, and California are pursuing federal waivers to adopt multiyear continuous Medicaid and CHIP coverage.
As Congress considers its 2022 year-end legislative package, it should guarantee 12 months of continuous coverage for children, mothers, and other vulnerable adults on Medicaid.
But this is not the case in all states: 17 states have no 12-month continuous child eligibility. Once the public health emergency expires, the likelihood that Medicaid/CHIP enrollees retain coverage depends on the state in which they reside. HHS estimates that 383,000 individuals who would be disenrolled are in the Medicaid coverage gap and will have no affordable coverage option when the public health emergency ends. To date, only 11 states have not adopted Medicaid expansion.
Oregon and Massachusetts are taking the lead by expanding continuous coverage
In September 2022, the HHS approved Section 1115 waivers for Massachusetts and Oregon to use Medicaid services to expand critical health-related social needs, including nutritional assistance and housing supports. Massachusetts is providing 12 months of continuous Medicaid and CHIP coverage for incarcerated beneficiaries upon their release and for 24 months of continuous coverage to individuals experiencing homelessness as a mechanism to reduce spells without health insurance. Oregon will become the first state in the nation to offer continuous Medicaid coverage to eligible children through age 6 without requiring verification for renewal.
To minimize coverage losses and disruptions across all states, federal action is needed well ahead of the end of the public health emergency. As Congress considers its 2022 year-end legislative package, it should guarantee 12 months of continuous coverage for children, mothers, and other vulnerable adults on Medicaid. The cost of continuous coverage is modest and yet would have a substantial impact on individual beneficiaries’ financial security and access to health care.
In 2023, millions of Medicaid enrollees will face coverage loss or disruption. The 117th Congress can stabilize recent coverage gains and protect low-income mothers and children by including continuous coverage, but only if it acts quickly.
The authors would like to thank Maggie Jo Buchanan and Madeline Shepherd for their contributions to this column.