The Medicaid program serves over 90 million people in the United States, providing individuals and families living on low incomes with health coverage. Enrollment grew during the pandemic, when a policy was put in place that required states to not kick anyone currently enrolled out of the program. This policy ended in April, and, since then, states have begun the eligibility redetermination process—known as Medicaid unwinding—that could lead to the largest loss of health coverage in U.S. history.
Over 7.4 million people have already been disenrolled from the Medicaid program, and this is only the beginning: predictions from the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services (HHS) last year estimated that approximately 15 million enrollees would lose their coverage over the course of the unwinding process—a figure that constitutes over 17 percent of the entire Medicaid and Childrens Health Insurance Program (CHIP) population during the public health emergency (PHE). But even these staggering predictions are likely underestimating the scope of the crisis, given that half of that number have already lost coverage just a few months into the process, and states have months more to continue redeterminations.
Medicaid unwinding also comes at a time when the nation’s maternal health crisis is more dire than ever. These issues are closely intertwined, with Medicaid financing nearly half of all births—and 65 percent of all births to Black women. With Black women and birthing people facing two and a half times the rate of pregnancy-related deaths as white women, we know that Medicaid is particularly important in addressing maternal health equity. This commentary will examine the implications for Medicaid disenrollment on maternal health, discuss how disenrollment will further degrade patient trust in the U.S. health care system among communities served by Medicaid, and provide recommendations on an equitable approach to Medicaid unwinding.
What Is Medicaid Unwinding?
Medicaid has been a crucial part of the U.S. social safety net since its establishment in 1965, providing health coverage to people with low incomes. The COVID-19 pandemic made the need for Medicaid—along with the Children’s Health Insurance Program (CHIP) which was established in 1997—even more evident. As individuals lost jobs—often along with their employer-sponsored health insurance—and needed continuous access to health care for acute infections and the related chronic conditions, Medicaid and CHIP were there for them. Combined enrollment for the two programs during the pandemic reached over 94 million people, a record number.
Enrolling people in health coverage plans—and keeping them enrolled—is a priority when it comes to public health. As the pandemic hit, policymakers had serious concerns about the harmful effects that disenrollment due to what is known as Medicaid churn would have in the midst of a public health emergency (PHE). And so, as part of the Families First Coronavirus Response Act, signed into law in March 2020, states were required to maintain continuous enrollment in their Medicaid programs for the duration of the public health emergency, as a condition for receiving increased federal funding.
Nationwide continuous Medicaid enrollment, however, is now a thing of the past. With the passage of the omnibus spending bill this past December, Congress delinked the PHE from continuous enrollment, allowing states to begin disenrolling individuals as of April 2023. States have begun this process in earnest, with over 7.4 million people already disenrolled from Medicaid.
Millions of enrollees losing coverage in such a short span is frightening, but equally troubling is that many of them may still be eligible. The vast majority of people disenrolled have lost coverage for purely procedural reasons: three-quarters of people who have lost coverage so far did so because they did not complete the renewal process, which could be due to a variety of reasons, including outdated contact information, a lack of understanding about the process, a missed deadline, or some other systems issue. The available data indicate that many people seem to be having trouble getting help; wait times at call centers and call abandonment rates are very high in many states, which is that much more challenging for the Medicaid population that may be working in jobs with limited flexibility or time to wait on hold for long periods of time. With states removing so many Medicaid enrollees from their programs all at once, together with pervasive communications and systems challenges, trust in the program is likely being dangerously eroded—which in itself may disincentivize people from re-enrolling.
Fortunately, one of the major issues with state level disenrollments has gained attention: auto-renewals using existing data sources—known as ex parte renewals—that were being conducted incorrectly in many states. Because of technical glitches in state Medicaid systems, states have been inappropriately measuring eligibility for auto-renewal at the family level rather than the individual level. This means that if one person in the family appeared ineligible for auto-renewal, no one in the household could be renewed this way, despite the fact that individuals within a household may have different eligibility requirements. This particularly impacts children, pregnant people, and other populations whose Medicaid eligibility is based on higher income limits than childless adults. In August, the Centers for Medicare and Medicaid Services (CMS), recognized this issue and asked states to certify whether their systems were doing ex parte renewals correctly at the individual level. Through this process, CMS identified thirty states (including Washington, D.C.) where ex parte–related disenrollments were processed incorrectly. The federal agency took a very important step by ordering a halt on procedural disenrollments occurring because of this flaw in ex parte renewals in these states and mandating that individuals erroneously deemed as ineligible through this flawed process have their coverage reinstated until the systems work correctly. While this is an absolutely critical fix, issues with enrollment are not limited to ex parte and not confined to those thirty states. CMS and states must remain vigilant, especially about procedural disenrollments and making sure people have access to affordable coverage as the unwinding process continues.
Maternal Health and Medicaid
Medicaid is a major source of coverage for prenatal care, labor and delivery, and postpartum care—especially, as noted above, for Black women and birthing people. The reason why it is a predominant source of coverage, especially for Black people, is because of historic and current structural discrimination that has systematically precluded Black people from accessing employer-sponsored insurance coverage. With Medicaid covering most births to Black women and birthing people—who experience the worst maternal health outcomes—strengthening the Medicaid program and extending its pregnancy-related coverage is an issue of equity. But even before this unwinding process began, pregnant people still faced too many significant barriers to accessing comprehensive Medicaid coverage.
Prior to 2021, the Medicaid program mandated sixty days postpartum coverage for new moms, with additional eligibility requiring a waiver. However, many of the serious health challenges that postpartum moms face happen after this sixty-day period. One third of all pregnancy-related deaths occur in the period between forty-three days and one year postpartum—and over 80 percent of pregnancy-related deaths are preventable. As part of the American Rescue Act Plan of 2021, Congress offered an option to states to extend postpartum coverage to twelve months through a State Plan Amendment, rather than a waiver; in the Consolidated Appropriations Act of 2022, Congress made this option permanent. As of September 21, 2023, thirty-seven states and the District of Columbia and Virgin Islands have implemented this extension. But, in many of the remaining states, pregnant Medicaid enrollees still lose their coverage a mere sixty days postpartum.
There are further disparities in Medicaid coverage, because not all states have expanded Medicaid coverage to the income threshold set by the Affordable Care Act (ACA). Because of the Supreme Court ruling in 2012 that made expansion optional, there is an unintended gap in coverage—wherein individuals may have incomes too high for Medicaid but conversely too low to qualify for subsidized coverage on the marketplaces established under the ACA. In the eleven states that have still not expanded Medicaid, there are additional concerns for maternal health. In these states, many newly uninsured individuals will fall in the Medicaid coverage gap and will be unable to afford new coverage.
The lack of universal implementation of many of these policies leaves pregnant and postpartum Medicaid enrollees vulnerable in too many states. Notably, in the case of Wisconsin—and in Texas, until the postpartum extension is implemented—residents face both challenges of a lack of Medicaid expansion and lack of postpartum coverage extension simultaneously.
The process of Medicaid unwinding only threatens to worsen maternal health outcomes, as many pregnant and postpartum people are left without continuous coverage during a critical period. The loss of postpartum coverage due to unwinding is a serious concern in every state, but is particularly dangerous in states where that coverage is only guaranteed for sixty days. Postpartum individuals will be at risk of losing their health coverage during a vulnerable period where access to health care is vital. Research shows that continuity of care improves health outcomes, and losing access to health insurance makes such continuous care difficult. When it comes to maternal health, lack of insurance during the perinatal period increases the risk of adverse birth outcomes.
It is imperative that pregnant and postpartum people—in addition to those who wish to become pregnant—are not left without coverage as the unwinding process continues.
Degrading Trust and Increasing Stress
Medicaid unwinding is problematic for maternal health equity not only because of the loss of coverage, but also because of the potential impact of this coverage loss on trust and trusted provider relationships, particularly among Black women and pregnant people.
There are many complex reasons why rates of maternal health mortality and morbidity are so high in the United States, and why the rates among Black women and pregnant people are particularly and tragically higher. One major reason is a lack of trust among many Black women and birthing people as they engage with and navigate the health care system. Trust and respectful relationships between patient and provider are always important, but especially during the crucial period during and after pregnancy. The disruptions in coverage and care that will undoubtedly occur during Medicaid unwinding will be a source of stress, confusion, and disempowerment for pregnant people and their families, and has the potential to further erode patient trust in the system by severing patient relationships with trusted providers. Research shows that the Medicaid program can already make enrollees feel disempowered, belittled, degraded, and without agency and autonomy—which also affects maternal health outcomes. The unwinding has the potential to degrade trust even further, especially if people are unaware they have been cut off from the program or confused about their eligibility and insurance status.
Factors that can improve trust in the system include clear, consistent, and reliable communication and support. Unfortunately, many states have struggled in these areas during the unwinding process so far. As mentioned above, data from early in the unwinding period suggests that, in many states, it was difficult for people to get through to call centers to get the help they needed. Survey data has also shown that many people are not even aware that Medicaid programs are now able to cut people off from coverage. The failure of states to ensure that communities—particularly Black communities—were aware of the upcoming losses of Medicaid coverage suggests that loss of eligibility will be accompanied by especially high confusion and further loss of trust. The process now in the thirty states with ex parte challenges may also cause confusion, as people may be reinstated without realizing they had been disenrolled in the first place and it is also unclear and confusing how long this reinstatement will last. Individuals presenting for care at the doctor’s office for a prenatal or postpartum visit only to find out that they are no longer covered will be devastating. Such patients, if still eligible, may be able to be reinstated, but this would not negate the feeling of lack of control and trust that would be imposed by such an experience, especially in a health care system that is already a source of distrust.
The most equitable way forward would be to maintain continuous enrollment in Medicaid—or at the very least, to put an end to procedural disenrollments and to make sure that people who are no longer eligible for Medicaid are connected to other sources of coverage. The recent CMS decision to pause procedural disenrollments and reinstate coverage for people who have been impacted by issues with ex parte renewals is a step in the right direction. CMS must continue holding states accountable for ensuring that redeterminations are being conducted correctly—not just in these thirty states but across all states, using the correct eligibility criteria and appropriate data sources. On their part, states must examine their own systems and processes to avoid disenrolling those that are eligible for Medicaid, paying particular attention to the higher income thresholds of special populations, including children and pregnant people.
Navigating Medicaid unwinding as equitably as possible also means taking additional efforts to get people the help that they need to maintain coverage. For pregnant and postpartum enrollees, it will be especially important for states to convey accurate information and reach enrollees proactively, especially through trusted partners such as community-based organizations and faith-based organizations. State Medicaid agencies will need to ensure that no postpartum enrollees are left without health coverage. In states that are newly implementing extended postpartum coverage in particular, enrollees may not be aware of the new requirements and state Medicaid systems may not be updated to reflect this extended eligibility.
An equitable approach also means utilizing all available resources and flexibilities to keep individuals enrolled, and re-enrolling eligible individuals who have lost coverage. States such as Massachusetts that are conducting outreach, including door-to-door visits, can serve as examples of how to ensure that Medicaid enrollees are able to fulfill requirements to maintain their coverage. CMS has made materials available to assist states, and other groups such as the National Health Law Project have made resources available to support advocates on the ground in the states.
The continuous enrollment during the pandemic demonstrated the potential to keep uninsured rates down and allow Medicaid enrollees to avoid administrative hurdles in order to maintain their coverage. Steps should be taken to replicate this success and avoid Medicaid churn in the future. CMS already has a proposed rule that would streamline enrollment and eligibility determination; this regulation should be finalized and implemented—and states should be required to implement the changes to avoid disenrollment from occurring for administrative reasons. States can also take action: some states have already submitted or received approval for Medicaid 1115 waivers to extend continuous eligibility.
Of course, ensuring continuous coverage and avoiding disenrollment must be addressed hand in hand with other policies to enhance Medicaid coverage and foster trusted relationships between birthing and postpartum people and their families and the health care provider and system. To ensure that all women and birthing people have adequate, continuous, and trusted coverage before, during, and after pregnancy requires every state to extend postpartum coverage, expand Medicaid, and provide people with the consumer assistance and support that they need.