Rural children and families are having to skip vital health treatments and even ending up in the emergency room, while already struggling rural clinics are losing more patients, as states cull their Medicaid rolls.

The process began in April 2023, when pandemic-era rules that prohibited kicking people off Medicaid coverage expired and states again began checking whether families met income restrictions. Nationally, nearly 70% of people who lost coverage did so for “procedural” reasons such as incomplete paperwork.

States with the largest drops in coverage also have large rural populations. The loss of coverage compounds struggles disproportionately experienced by rural children and families, experts say, including clinician shortages, long drives to care and poorer health outcomes.

Eight states — Alaska, Arkansas, Colorado, Idaho, Montana, New Hampshire, South Dakota and Utah — had fewer children enrolled at the end of last year than before the COVID-19 pandemic, according to a recent analysis by the Georgetown University Center for Children and Families.

“Medicaid is even more of a lifeline for rural communities than it is for urban ones,” said Joan Alker, the center’s executive director. “There are quite a number of states with large rural populations where things are not going well — so that’s very problematic.”

A year into the process, frequently referred to as Medicaid “unwinding,” South Dakota, Montana, Utah, Texas and Idaho have seen the largest plunges in rates of children losing coverage, with an average of 25% fewer children enrolled in those states since April 2023.

In rural areas, which on average have higher rates of poverty, children are less likely than their urban counterparts to have had a medical checkup or dentist visit in the past year, the center reported.

In Idaho, where 35 of 44 counties are considered rural, “a lot of this is attributed to the state rushing through the process to conduct [income eligibility] redeterminations in six months,” said Hillarie Hagen, health policy associate at Idaho Voices for Children, a group that advocates on policies affecting children. “The rush and arbitrary deadline resulted in an alarming number of children losing coverage.”

Hagen added that the change “is putting families in a very difficult position of having to choose to delay care or risk significant financial burden on their family.” Rural Idaho counties tend to be poorer than urban counties, and Hispanic and Native American state residents are more likely than white residents to be living in poverty.

Dr. Noreen Womack, a pediatrician at a mobile clinic for kids in Boise and nearby rural communities in Idaho, run by St. Luke’s Children’s Hospital, said not a week goes by that she doesn’t see a patient who has lost Medicaid coverage — and who is sometimes unaware they’re now uninsured.

When kids’ parents tell her they have Medicaid, she said, she’s learned to ask, “Are you sure?”

She said she regularly sees children and teens who are no longer covered and who stopped taking critical treatments, such as antidepressants and ADHD medications, harming their well-being and school performance.

Womack recalls one 7-year-old boy who was no longer enrolled in Medicaid and whose family couldn’t afford his ADHD medication. He was on the verge of being expelled from school.

He looked at Womack, scared and dispirited. “‘I’m having trouble staying on task again, and they’re going to kick me out,’” she recalled him saying.

“It’s so sad, because he’s only 7,” she said. “These families are already so much living on the edge, and it’s hard for them.”

Other young patients who have gone undiagnosed for asthma have ended up in the ER, she said. “One of the things we’re trying to do is decrease the amount of unnecessary emergency department visits.”

As in many states, patient navigators have been key to helping families work through the complex process of renewing Medicaid if they qualify, Womack said.

Idaho’s Department of Health and Welfare acknowledged the rapid pace of its redetermination process, but expects the number of enrollees to return to normal.

“Idaho was one of the very first states in the nation to start and finish unwinding activities while many other states are still in the process of completing all initial renewals,” spokesperson AJ McWhorter wrote in an email to Stateline. He added that the agency “early on identified and prioritized individuals who were likely no longer eligible for Medicaid. As other states continue to complete their unwinding activities, we expect these numbers to begin to normalize.”

Utah has seen the nation’s highest overall disenrollment rate at 56%, followed by Idaho and Montana at 55%, and Oklahoma, South Dakota and Georgia, which have each seen coverage loss rates of 50% or higher.

Utah’s state Medicaid office asserts that because states are at different stages in unwinding, disenrollment rates between states can’t be compared “apples to apples.” The state’s unemployment and poverty rates are lower than the national average, which means Utahns have fewer uninsured people and fewer Medicaid enrollees to begin with, said Kevin Burt, who oversees Utah’s Medicaid eligibility determinations at the state Department of Workforce Services.

“Having just finished unwinding, I don’t think the data is quite settled,” Burt added.

Jennifer Strohecker, Utah’s Medicaid director, said her office has been working with hospitals, clinics and nonprofits to help with redeterminations.

“It is our objective that if a person is eligible for Medicaid, we want them to have that coverage,” she said, adding that the state aimed to make sure the health centers “had the right resources and tools to meet the needs of the patient as they saw them, and help them with some of the [eligibility] questions.”

Families of color

Across small towns and rural areas nationwide, Medicaid covers 47% of children and 18% of adults, compared with about 40% of children and 15% of adults in urban counties, the Georgetown center found in an analysis of U.S. Census Bureau and Medicaid data.

Compared with urban residents, those in rural areas are more likely to have poorer overall health.

Many states with the highest rates of Medicaid disenrollments also have large American Indian and Alaska Native communities. Federal tribal affairs and Medicaid officials say the program plays a critical role in filling gaps in funding for tribal health care.

Chickasaw Nation member Dr. Jesicah Gilmore, a family medicine doctor and chief medical officer of the Indian Health Care Resource Center in Tulsa, Oklahoma, said the loss of Medicaid coverage has left many of her patients unable to obtain or pay for specialist care, such as cardiology or nephrology. While the center is in the city, it’s also a pillar for rural Native patients, who drive hours to the clinic for primary care and referrals.

“Part of what we’re seeing is that then they’re having difficulty accessing referral services or some of the specialty tests,” she said. “It’s provided quite a strain on our system.”

Many lost coverage because they no longer qualified or because they didn’t finish paperwork, leaving them to pay out of pocket — or forgo care if they can’t, she said.

“We have staff members here who specifically help patients with paperwork and can help navigate some of the online systems — many of our patients don’t necessarily have continuous access to the internet,” she said. “It does get worse when patients are uninsured, because they have no other recourse for care, other than going to the ER.”

She remembers one patient recently who lost Medicaid coverage two days before an orthopedic appointment for extreme knee pain. Gilmore estimates it could be another three months before her patient can get a knee replacement approved by a specialist and for the clinic to help her find and apply for another payor, such as the tribe, and up to six months until the actual surgery.

“It was affecting her ability to continue working, walking, standing,” she said. “Who’s going to pay for this appointment? This patient has been waiting to get this, hopeful. … Now, she’s kind of in a holding pattern.”

Loss of revenue for rural clinics, hospitals

Gilmore worries the longer-term fallout for her clinic will be a hit to revenue due to caring for uninsured rural patients. The clinic was planning to expand services “but might not be able to,” she said.

That concern is echoed in other rural health care settings.

Straddling the Utah-Arizona border is the Creek Valley Health Clinic, serving a rural area that the Utah Department of Health says is one of the most underserved regions in the state. The area lacked a primary care clinic for over a decade, and many patients would drive an hour or more to the nearest hospital before the clinic opened in 2019.

“We inherited such a sick patient population with really high rates of chronic disease and unhealthy habits,” said Hunter Adams, the clinic’s co-founder and CEO. Adams said the clinic had helped lower ER visits for primary care.

Since the clinic opened, Adams said, the patient base has seen improved rates of depression screening, diabetes control and childhood obesity.

But since the unwinding, the clinic saw an 8% drop in Medicaid patients. That, along with changes to pharmacy contract programs and expiring COVID-19 assistance grants, has put the nascent clinic in a bind, Adams said.

“It’s kind of a three-legged impact to our budget,” he said. “We’re in this kind of hard space where we’re not big enough to really contract and negotiate payment change, but we’re also big enough that we feel these budgetary changes … with the Medicaid unwinding.”

Alan Pruhs, executive director of the Association for Utah Community Health, which represents health centers across the state, estimated that those clinics have seen on average a 12% to 15% reduction in the Medicaid patient population, with some clinics losing up to 20% of Medicaid patients.

“Fiscal fragility just was ratcheted up a few more notches, because we’re now losing more revenue,” Pruhs said.

He’s hearing from clinics that serve particularly vulnerable clients, such as opioid patients, dropping out of rehabilitation programs because of losing Medicaid.

Pruhs said an increase in uninsured patients can further add financial pressure on already strapped rural community health clinics.

“From a health center perspective, your uninsured patient now comes in and it’s actually costing you money — it’s not generating revenue.”

It’s now been four corporate reporting quarters since the start of the PHE unwinding on April 1, 2023. During that time, net national Medicaid enrollment—the combination of disenrollments from redeterminations, re-enrollment by some of those terminated, and new enrollments—has fallen by 13.1 million, including 5.0 million children. Of the disenrollments, 70 percent have been for procedural reasons, not the result of an actual determination of ineligibility. Three fourths of all Medicaid enrollees are covered through managed care organizations (MCOs) in 42 states (including the District of Columbia). Five national companies together dominate half of this market: Centene, CVSHealth/Aetna, Elevance Health, Molina Healthcare, and UnitedHealth Group. The “Big Five” have now reported their Q1 2024 financial results. How has the PHE unwinding affected them?

Figure 1 tells the enrollment tale for the Big Five as a group. When the PHE began in March 2020, their total Medicaid enrollment stood at 30.1 million. By the time the unwinding began, their total Medicaid enrollment had increased by 14.1 million, to 44.2 million. A year later, their total enrollment was 37.8 million, a drop of 6.4 million, or 14.4 percent. Despite this decline, total Medicaid enrollment for the “Big Five” in March 2024 is still 7.7 million higher than it was in March 2020.

Figure 1: "Big Five" Medicaid Enrollment During and After the COVID-19 Public Health Emergency

Table 1 tells the enrollment tale for each of the Big Five. Four of the companies reported Medicaid enrollment declines between the quarters ending March 31, 2023 and March 31, 2024. Centene, the company with the largest Medicaid enrollment, lost the largest number of enrollees, a little over 3 million, a drop of 18.5 percent. Aetna, now a business segment of CVSHealth, lost 375,000 Medicaid enrollees over that period, a decline of 13.4 percent. Elevance Health, formerly Anthem, had the largest Medicaid enrollment decrease in percentage terms: 21.5 percent, reflecting a decline of 2.6 million. UnitedHealth Group lost 700,000 Medicaid enrollees over the year, a decline of 8.3 percent.

Only Molina Healthcare, the smallest of the Big Five, reported an increase in Medicaid enrollment, from 4.8 million in Q1 2023 to 5.1 million in Q1 2024 (6.0 percent). How did a receding tide not lower all five boats? Management’s explanation: disenrollments due to unwinding redeterminations (50,000 in Q1 2024, 550,000 to date) have been offset by enrollment increases due to the start of new contracts in Iowa and Nebraska as well as an “expanded California Medicaid platform including Los Angeles County.”

Molina’s results underscore the point that enrollment data reported by each of the companies are net numbers, reflecting a combination of enrollment losses and gains. Enrollment losses could result not just from the unwinding, but also from the failure to keep Medicaid contracts in state procurements as well as current enrollees switching to a different MCO. Enrollment gains could come from the enrollment of newly eligible individuals, the award of new contracts in state procurements, the launch of new state Medicaid managed care programs (e.g., Oklahoma on April 1), and/or the acquisition of competitors.

Table 1: "Big Five" Medicaid Enrollment, Q1 2024

Table 2 tells the revenue tale, at least in part. (CVSHealth/Aetna and Elevance Health simply don’t report their Medicaid revenues; it’s unclear why investors would be uninterested in these payment streams). Between Q1 2023 and Q1 2024, Centene’s Medicaid revenues were down $767 million, or 3.5 percent; Molina’s were up $1.1 billion, or 18 percent; and UnitedHealth Group’s were up $1.7 billion, or 9.3 percent. Combined Medicaid revenues rose by $2.1 billion, or 4.5 percent.

Table 2: "Big Five" Medicaid Revenue Results, Q1 2024

This seems paradoxical. For all three companies, total Medicaid enrollment decreased by 3.4 million year-over-year, but total Medicaid revenues increased by $2.1 billion. At the individual company level, Centene’s Medicaid enrollment and revenues both decreased, while Molina’s both increased.

On the other hand, UnitedHealth Group’s Medicaid enrollment went down by 8.3 percent while its Medicaid revenues went up by 9.3 percent year-over-year. Can it be that every Medicaid enrollee United lost increased its revenues by $2,490? What kind of managerial magic produces that result? It’s a puzzlement. UnitedHealth Group’s 10-Q doesn’t give an explanation, and the financial analysts did not ask about it during the company’s earnings call (which is understandable given the Change Health debacle).

Only two of the Big Five disclosed medical loss ratios specific to their Medicaid lines of business for the quarter: Centene (90.9%) and Molina Health (89.7%). (The way in which these companies calculate MLR—costs of medical care as a percentage of premium revenue—differs somewhat from the way the federal regulations specify Medicaid MLRs should be determined).

While the financial analysts, as well as company managements, would prefer that these MLRs be lower, they nonetheless help to explain why the Medicaid managed care market continues to be attractive to the Big Five, among others. As Molina’s 10-Q report explains: “the underlying medical margin, or the amount earned by the Medicaid, Medicare, and Marketplace segments after medical costs are deducted from premium revenue, represents the most important measure of earnings reviewed by management….” Molina’s Medicaid margin in the quarter was $775 million.

And now for some forward-looking statements. Readers are advised that actual results may differ materially from these expectations.

We at CCF estimate that, by the end of June, the majority of states will have completed redeterminations of eligibility for all individuals enrolled in Medicaid at the time the unwinding began last year. There’s some uncertainty around this estimate, given the different cadences at which states have conducted and reported their redeterminations. Based on our analysis of CMS enrollment and unwinding data, we do know that as of February or March, 29 states had processed over 75 percent of their pre-unwinding caseload; another 19 states had processed between 50 and 75 percent; and one state (Alaska) had processed less than half. Some states have completed their unwinding redeterminations (e.g., Arizona, West Virginia) and some have begun conducting regular redeterminations at the same time as they continue their unwinding redeterminations.

The implications of the unwinding for each of the Big Five will continue to vary depending on the states in which they operate subsidiaries. Nonetheless, for the Big Five as a group, Medicaid enrollment is likely to continue to decline at least through Q2. Whether Medicaid revenues will continue to increase as Medicaid enrollment declines is anyone’s guess.

View figures and tables here

Three weeks ago, Cierra Clowney, 24, of Spartanburg, didn’t know how to swaddle a baby. Two and a half weeks ago, she became a mom.

Clowney is one of the 875 families Hello Family has helped provide free pre-natal and post-natal services, education, and pregnancy and childcare resources to specifically, since October 2021 as part of an initiative aimed to improve the outcomes of children and new mothers in Spartanburg.

Hello Family is comprised of four Spartanburg-based non-profits: Family Connects, BirthMatters, Triple P and Quality Counts. In total, Hello Family has helped more than 1,800 families

“I didn’t know hardly anything about raising a child and they can explain everything and help you with that whole process,” said Clowney. “They are there step-by-step. They will not leave you.”

Clowney relied on a Doula from the non-profit BirthMatters, a person experienced in the process of childbearing who coaches and mentors those experiencing pregnancy.

According to the results of a simulated study conducted by the Washington D.C.-based think-tank, Urban Institute, from Jan. 1 – Dec. 1 2022, Hello Family would have helped to decrease NICU admissions by 0.9% and low birth weights by 6.7%.

“What we have is without Hello Family, low birth weights would be almost double, it’s telling us that NICU admissions would be a little higher and it’s telling us there would be more avoidable emergency room visits,” said Kaitlin Watts, director of Center for Early Childhood Success at Spartanburg Academic Movement.

For Clowney, her nearly three-week-old baby boy, Kendrick Clowney, brings a smile to her face when she looks at him and also at times, stress.

“I definitely would be very stressed out [without BirthMatters], I don’t know how I would really make it honestly,” said Clowney. She said she still suffers from Postpartum Post-Traumatic Stress Disorder (PTSD) as a result of giving birth and regularly goes to therapy.

Clowney admitted for her to get the help she needed, she had to swallow her pride.

“I reached out because you need help,” said Clowney. “You do need help. It takes a lot for me to put things aside, and accept help and that’s what I had to learn to do.”

“We’re a community and a community helps one another,” said Watts. “We serve one another. So, these kids we’re talking about right now, one day, they’re going to be your neighbors. They might be the ones serving you in the stores. Our goal is to be the best we can be and have the strongest and healthiest community and that’s what this is doing.”

Another new mom who has utilized the services of Hello Family is Yasmin Wilson, 27. Her two-month-old daughter, Ysabella, was born in March. Before then, she said she had no idea how to feed a newborn baby.

“All the resources that [my Doula] gave me as far as being able to prepare myself and my body, and then having issues with [Ysabella] after she was born; having those resources has been so helpful,” said Wilson.

Wilson and Clowney say they relied on their Doulas from BirthMatters to get them through their pregnancy. But there are more services that Hello Family offers like having a registered nurse from Family Connects, a branch of Spartanburg Regional Healthcare System, make home visits to check up on the mother’s and baby’s health.

Anjonique Fernanders is one of those nurses who says she was initially surprised by the number of mothers who didn’t know much about raising a newborn child when she started working with Family Connects two years ago.

“Some moms may not be aware, ‘Well what should my baby be gaining?’ and ‘What should my baby be eating?’, so we want to relay that information to them,” said Fernanders.

Fernanders said one thing many new mothers should be looking for is high blood pressure. It’s something she checks when she makes home visits.

“Parenting is challenging,” said Fernanders. “Giving them the resources can help better support them.”

Watts said as of now Hello Family is only available to those in the City of Spartanburg’s limits but is in the process of expanding and will complete that process by 2030.

"I signed the Help Not Harm bill into law, which protects our state's children from irreversible gender transition procedures and bans public funds from being used for them," McMaster said in a post on the social platform X Tuesday. "I look forward to joining legislators and supporters at a ceremonial bill signing in the Upstate next week." The bill, House Bill 4264, states that a "physician, mental health provider, or other health care professional shall not knowingly provide gender transition procedures to a person under eighteen years of age" and that those who do so "shall, upon an adverse ruling by the appropriate licensing board, be considered unprofessional conduct and shall be subject to discipline by the licensing entity with jurisdiction over the physician, mental health provider, or other medical health care professional."

"Across the state, from the Lowcountry to the Upstate, South Carolinians are mourning the passage of H.4624, which will make it immeasurably harder for transgender youth and many adults to access the life-saving healthcare that they need and deserve," Chase Glenn, a leader in the LGBTQ advocacy group SC United for Justice & Equality, said in a statement in a Tuesday press release. "But let me be clear: This loss does not crumble a movement," Glenn continued. "Our movement supporting transgender people in South Carolina is louder and stronger than it's ever been. We've marched at the State House, we've told our stories, and we've made sure our lawmakers heard from us. Now, we will do everything in our power to support our community through this crisis." Jace Woodrum, the executive director of the American Civil Liberties Union (ACLU) of South Carolina, said in a press release Tuesday that the group stands "in grief and solidarity with LGBTQ South Carolinians, who are increasingly under attack by our own government."

"We can put to rest the notion that the governor cares about limited government and personal freedom," Woodrum's statement continues. "With the stroke of a pen, he has chosen to insert the will of politicians into healthcare decisions, trample on the liberties of trans South Carolinians, and deny the rights of the parents of trans minors."

Looking back over South Carolina's civic life, most historians would agree that Carroll Campbell has been among our state’s most effective governors. It was Campbell, a Republican with a General Assembly that was 61% Democratic, who shepherded through a comprehensive restructuring of state government in 1993.

It is hard to imagine today, but before the former Greenville congressman’s reform plan was enacted, South Carolina’s governor was hands-down America’s weakest. State agencies were run by boards and commissions, some of which included legislators. There was no governor’s Cabinet, and executive authority was diffused so widely and thinly that citizens often wondered who was in charge.

There were a number of reasons for Campbell’s success, some of which seem almost paradoxical. He was clearly very conservative, but he believed passionately in reform. He was a fan of the “too conservative” Ronald Reagan, but he also decried “horse and buggy government.” He favored shrinking the size of government and knew well the balance that the framers sought to build into public policy: Power should be concentrated just enough to ensure effective governance, but not enough to open the door to tyranny.

Campbell’s conservative but reformist legacy and his understanding of the appropriate balancing of power speaks into the final stage of a current debate; following the division of DHEC into separate environmental and health agencies, the General Assembly is taking the next step by streamlining the health functions of six state agencies into the Executive Office of Health and Policy.

Unfortunately, even after the Senate passed S.915 by a vote of 44-1 and the House by a margin of 98-15, some concerns have prevented the enactment of the legislation to establish this new department from pieces of existing ones. But those concerns aren’t based in reality:

• There is no South Carolina version of Anthony Fauci here. The governor can remove the executive secretary of Health and Policy at any time, and the General Assembly can still direct the governor to remove a Cabinet officer with a two-thirds vote in each chamber.
• Some powers will move, but no new powers will be created. In at least one case, emergency powers on the books since 1908 were modified during the S.915 amendment process to clarify that only the governor can exercise them.
• The governor’s choice for secretary will not be micromanaged with a long list of bureaucrat-friendly required qualifications in the enacting statute.
• Employees of the consolidating agencies and offices will move to positions in the new component departments, but natural redundancies will create the opportunity for savings. The General Assembly can tighten the purse strings as well.
• One of the remaining post-Campbell unelected and unaccountable governing boards, the DHEC board, is dissolving, and the health policy buck will finally stop with the governor.
• There has been no unseemly rush. The massive restructuring legislation under Campbell was accomplished in about five months. This much-less-ambitious health restructuring will have taken about the same amount of time from beginning to end. Factoring in time spent on the legislation splitting the Department of Health and Environmental Control, the Office of Health and Policy timeline has been even longer than the 1993 restructuring.
• Thanks to a subsequent reform, which established legislative oversight committees, the new agency will appear regularly before the Senate and House to answer for its actions. Citizens also have the ability to lodge a complaint about the agency with the oversight committees.

The establishment of the Executive Office of Health and Policy represents a significant opportunity — not only to save taxpayer dollars by eliminating duplication that went unaddressed in 1993 and 2014, but to serve our citizens more effectively, particularly those with complex health needs who have been underserved by the confusion that comes from existing unaligned agencies.

But the new agency will not have absolute power. The supreme authority of the governor, oversight and confirmation procedures already in place and additional safeguards built into the legislation are designed to protect the rights of citizens. There are additional political, legal and administrative remedies outside of these as well.

The Executive Office of Health and Policy is a reform whose time has come, a reform that I feel sure the Ronald Reagan Republican Carroll Campbell would have warmly embraced.

Oran Smith, senior fellow at Palmetto Promise Institute, served in the Campbell administration.

Video: Will South Carolina expand Medicaid?

Video: Could Medicaid expansion soon be on the table in South Carolina?

Strides have been made towards reducing the numbers of people without health insurance in the U.S. In August 2023 the Department of Health and Human Services announced that the national uninsured rate reached an all-time low of 7.7% during the first quarter of the year. The number of uninsured declined from 31.6 million to 25.3 million over the 2020–23 period.

Importantly, the largest drops in numbers of uninsured took place among lesser well off individuals whose household income was either below 100% or between 200% and 400% of the federal poverty level. But it’s millions of these folks, who have been disenrolled from Medicaid since the Covid-19 pandemic public health emergency ended in April of last year, who now find themselves uninsured. This harks back to the persistent issue of tens of millions of Americans lacking health insurance on any given day.

STAT News reported KFF data that roughly 21% of the people who were enrolled prior to the redeterminations, or almost 20 million, lost coverage at least temporarily. Meanwhile, 45%, or 42 million, were confirmed as Medicaid-eligible. However, for the remaining 31 million people, renewal of coverage is pending. Moreover, data show that approximately five of the more than 20 million who have been disenrolled during the post-pandemic eligibility reviews are still uninsured.

During the public health emergency caused by the Covid-19 pandemic, Medicaid’s annual (re)determinations of enrollee eligibility were paused as part of a continuous coverage provision included in the 2020 Families First Coronavirus Response Act. Through March of 2023, enrollment in Medicaid and the Children’s Health Insurance Program grew by more than 23 million people.

However, since last April Medicaid restarted the determination process to check to see if enrollees are still eligible. As a result, millions are no longer enrolled in Medicaid and have no other coverage. This has often been due to procedural and administrative reasons, meaning individuals did not complete the necessary paperwork, in part because former enrollees did not properly understand the process and specifically what was needed for them to retain coverage.

The impact on individuals varies enormously by state. For example, Utah disenrolled the highest percentage (60%) of its completed Medicaid redeterminations while Maine disenrolled the lowest (12%).

Disenrollment numbers have surpassed initial expectations set by the federal government. Last year the Biden Administration projected that 15 million in total would be removed from the rolls.

What’s concerning is that about 40% of the eligibility redetermination process remains to be completed, which implies there’s still a lot more disenrolling ahead which will result in more people added to the uninsured tally.

Many people who are no longer eligible for Medicaid can sign on to their employer’s health plan, should that be offered to them. Further, for some who must obtain their own health insurance, state marketplace exchange coverage is available. To illustrate, through November 2023, nearly 2.3 million people had transitioned from Medicaid to a private marketplace plan. This service is available in every state to help individuals, families and small businesses shop for and register with an affordable medical insurance plan. Some states have their own marketplace platforms. Other states use the federally run platforms. Created by the Affordable Care Act, these portals gives people access to health insurance plans of all types from a variety of insurers.

As the independent health insurance guide healthinsurance.org explains, in the majority of states people can sign up with a state marketplace plan at any time before July 31, 2024, as part of an extended “unwinding special enrollment period.” Also, individuals who no longer qualify for Medicaid based on their level of income may still be able to obtain subsidies to help offset the cost of their health insurance premiums.

Nevertheless, as Medicaid unwinding continues hundreds of thousands and perhaps millions more people will become uninsured. This calls to mind the longstanding discussion of both lack of health insurance for several tens of millions in America and the tenuous nature of medical coverage for many others.

There's significant variation among states when it comes to the ongoing Medicaid disenrollment process. A new Robert Wood Johnson Foundation analysis has found that while enrollment in Medicaid and the Children's Health Insurance Program (CHIP) declined by 9 million people from April to November 2023, eight states had Medicaid disenrollments surpassing 100% of projected net disenrollments.

Nationwide, aggregate net disenrollment as of November 2023 was at 60.5% of projected total disenrollment throughout the unwinding. The eight states exceeding 100% are Arkansas, Idaho, Iowa, Montana, New Hampshire, Oklahoma, South Dakota and Texas.

At the same time, 19 states had net disenrollment of 50% or less of the firm's projected total net disenrollment.

The net disenrollment rate was much higher for children than adults nationwide, largely because of exceptionally high child net disenrollment in some states. Total net disenrollment among children was 84.2% of the expected total, while total net disenrollment among adults was 50.7% of RWJ's estimates.

Seven states had adult net disenrollment greater than 100% of expected disenrollment, while 12 states had child net disenrollments that exceeded that threshold. This means current Medicaid enrollment levels in these states are below the historical trend, the report found.

States that publicized their intention to complete the unwinding in less than 12 months, states that obtained few federal waivers to streamline renewal, and states that prioritized the renewal of those likely to be ineligible all had notably higher overall net disenrollment rates relative to other states. States with any of these three characteristics had net child disenrollment over 120% of the projections, on average.

WHAT'S THE IMPACT?

In 2020, Congress passed the Families First Coronavirus Relief Act, which barred states from disenrolling people from Medicaid or child Medicaid coverage funded through CHIP during the pandemic unless they requested it. This led to record-high enrollment growth of more than 20 million Medicaid members than before the requirement.

Three years later, Congress passed legislation to end the continuous coverage requirement effective March 31, 2023, and allowed states to resume the Medicaid eligibility redetermination process, also known as Medicaid "unwinding."

Some are concerned that states are moving too fast and that many enrollees could lose coverage for procedural reasons even though they remain eligible. Others argue that slowing down the unwinding leaves ineligible people on the rolls at an unnecessary cost to both state and federal budgets.

The results from the analysis are likely to change when more recent data becomes available, particularly as more states complete the unwinding process, originally scheduled to end in June. Some variation between states may be because of their different start dates, authors said.

THE LARGER TREND

Data published by KFF in January showed an estimated 16 million beneficiaries had lost Medicaid coverage to that point.

There are reasons to expect disenrollment rates to moderate in the second half of the unwinding as states reduce procedural disenrollments and work through "likely ineligible" populations, the report said.

To date, 40 states and the District of Columbia have adopted Medicaid expansion, and 10 states have not adopted the expansion, according to a KFF report in December 2023. Originally a mandate of the ACA, Medicaid expansion was left to the determination of individual states following a ruling by the Supreme Court.

In the 10 states that have not adopted Medicaid expansion, nearly 1.5 million uninsured individuals fall into the "coverage gap," and are not eligible for Medicaid or ACA Marketplace subsidies, KFF said.

As readers of Say Ahhh! know, I have been tracking monthly data from the Centers for Medicare and Medicaid Services (CMS) on the number of people who were either previously enrolled in Medicaid or had experienced a denial or termination during unwinding who then selected a marketplace plan. At the end of April, CMS issued new data for January 2024, which was the last month of the 2024 Open Enrollment Period in nearly all states.

In January, another 1.15 million people lost their Medicaid coverage due to unwinding of the Medicaid continuous coverage protection, of which 67 percent were procedural disenrollments and 33 percent were due to a finding of ineligibility. Separately, CMS reported that nearly 484,000 people who were either previously enrolled in Medicaid in federal marketplace states or had experienced a denial or termination in state-based marketplace states selected a marketplace plan in the same month. That constituted about 42 percent.

Compared to total marketplace enrollment among those losing Medicaid in December, total January marketplace enrollment fell by 57 percent. As a result, the rate of marketplace enrollment among those disenrolled from Medicaid also decreased, compared to 83.9 percent in December — the second month of the 2024 Open Enrollment Period — and 54.2 percent in November, the first month of the Open Enrollment Period. (In addition, another 33,600 or 2.9 percent enrolled in a Basic Health Plan in New York and Minnesota in January, with nearly all of that BHP enrollment occurring in New York.) Cumulatively, through January 2024, compared to the 14.85 million people disenrolled from Medicaid, about 3.9 million or about 26.3 percent enrolled in marketplace plans. (The figure rises to 28.2 percent if including Basic Health Plan enrollment.)

As each of the blogs about previous CMS data releases noted, to provide context to these figures, federal researchers from the HHS Office of Assistant Secretary for Planning and Evaluation (ASPE) previously projected that of the 15 million people expected to lose Medicaid during the unwinding, nearly 2.7 million people — or about 18 percent —would be eligible for subsidized marketplace coverage. While this data represents only the outcome of unwinding through January, it indicates that the cumulative transition rate to marketplace coverage is significantly surpassing the expected pace, after many months of falling well short. What may have happened is that many people who were eligible for marketplace subsidies and who could have immediately enrolled in marketplace plans through a Special Enrollment Period after being disenrolled from Medicaid did not do so and became uninsured. However, after a gap in coverage, many eventually found their way to the marketplace during the 2024 Open Enrollment Period, which began on November 1, 2023. Marketplace enrollment soared to a historic high of 21.45 million during the 2024 Open Enrollment Period.

Notably, at the current pace of disenrollments, the total number of people disenrolled from Medicaid once unwinding is completed will well exceed the original 15 million projection from ASPE and the 17 million projection from other analysts such as KFF — with our latest data showing 18.8 million people have already been disenrolled. And the share of total disenrollments that are procedural terminations remains very high — 70 percent overall according to our latest data — with many of those losing coverage, especially children, likely remaining eligible. In comparison, ASPE estimated that 45 percent of those who would be disenrolled from Medicaid, including for procedural reasons, would remain eligible for Medicaid. Finally, while children’s enrollment in the marketplace rose to 2.16 million in the 2024 Open Enrollment Period, an increase of 611,000 — or about 39.5 percent — from the 2023 Open Enrollment Period, that increase offsets only a modest share of the 4.94 million in total net Medicaid enrollment losses among children (according to our latest data) since unwinding of the continuous coverage requirement began last year. Moreover, children still account for only about 10.1 percent of total marketplace enrollment in 2024.

Marketplace plans will be a valuable source of affordable, comprehensive health coverage but that will likely be the case for only several million people — and a relatively modest number of children —who lost their Medicaid coverage during unwinding, despite the large increases in transitions to marketplace plans during the Open Enrollment Period months of November, December and January. As our recent analysis of child Medicaid enrollment data shows, through December 2023, there was wide variation in Medicaid/CHIP child enrollment declines among states during unwinding of the continuous coverage requirement. Some states prioritized rapid disenrollment of children and adults, had high rates of procedural terminations and low rates of ex parte renewals and as a result, had larger child enrollment declines. But other states took a different approach. They strove to maximize successful renewal of eligible children and are adopting strategies moving forward to keep eligible children enrolled and avoid inappropriate coverage losses upon renewal.

For example, as they finish unwinding and post-unwinding, states should further improve their ex parte renewal rates, ensure full compliance with all federal requirements for Medicaid renewals, and continue the renewal flexibilities that were provided by CMS during the unwinding process. Moreover, to further increase child Medicaid enrollment to offset these large coverage losses from unwinding, states should also take up various actionable strategies to promote continuous coverage for children and families, as reinforced in a CMS Informational Bulletin issued in December. States should also take up multi-year continuous eligibility for children, which an increasing number of states are adopting, in addition to successfully implementing mandatory 12-months continuous eligibility for children which took effect on January 1, 2024. Finally, states and the federal government will need to work together on robust outreach and enrollment efforts in 2024, including back to school campaigns, to target eligible children, families and other adults who were disenrolled for procedural reasons so they can be reenrolled in Medicaid as quickly as possible.

We're nearing the six-month mark since North Carolina opened up enrollment to its expanded Medicaid program. Since December, 448,242 North Carolinians have been added to the rolls for full coverage, the state Department of Health and Human Services tells Axios.

Why it matters: The expansion meant that another 600,000 residents — nearly 6% of the state's population — became eligible for coverage they previously might not have been able to afford, from maternity care to prescription drugs.

Context: Gov. Roy Cooper has prioritized Medicaid expansion since he took office in 2017. Republicans had long been wary of expanding Medicaid benefits, initially citing financial concerns, the News & Observer reported.

• Last year, lawmakers in Raleigh reached a bipartisan agreement to expand Medicaid once a state budget was passed.
• North Carolina became the 41st state to adopt the Affordable Care Act Medicaid expansion when Cooper signed the legislation last year.

Between the lines: Medicaid signups are increasing in North Carolina's rural counties, including Edgecombe, Robeson, Swain and Graham, according to the state's Medicaid expansion dashboard.

• "Relative to the size of [the] population, we are outpacing signups in our rural communities more than urban communities," N.C. Health and Human Services Secretary Kody Kinsley recently told WRAL.
• A smaller share of the population is enrolled in large, urban counties. In Mecklenburg, for instance, 44,177 people are on the rolls — 6% of the adult population. In Wake County, the number is 27,480 people, representing 3.6% of the adult population.

Zoom out: Medicaid covers most health care services at little or no cost to patients, from emergency services to preventative care.

• Most of the prescriptions being filled under the expansion are for seizures, asthma and other chronic conditions, NCDHHS officials say.
• "Preventative, rehabilitative, services that people need and simply went without ... now will be able to benefit from," deputy secretary for NC Medicaid Jay Ludlam told Axios.

• The expansion opened up enrollment to non-elderly adults with incomes up to 138% of the Federal Poverty Level (FPL) ($34,307 for a family of three in 2023), according to the nonprofit KFF.

What's next: State health officials are working to engage with communities to get residents in need to sign up for Medicaid through town halls, distributing bilingual material, and other outreach, Ludlam says.

What they're saying: "North Carolina serves as an example to other states who have yet to expand Medicaid health care coverage, because Medicaid expansion can and will save lives," U.S. Health and Human Services Secretary Xavier Becerra said in a recent statement.