The End of the COVID-19 PHE and Medicaid Continuous Coverage: Health Equity Implications

Health Highlights

Editor’s Note: In a new Expert Perspective—prepared for the Robert Wood Johnson Foundation’s State Health and Value Strategies program—Manatt Health highlights the urgent need for states to retain coverage gains for Medicaid-eligible individuals at the end of the COVID-19 public health emergency (PHE) and to ensure that coverage retention efforts include an equity focus. To that end, the Expert Perspective, summarized below, concludes with recommendations for states to maximize coverage retention. Click here to access a free copy of the full Expert Perspective.


Medicaid enrollment has increased by over 10 million (or 15 percent) from February 2020 through February 2021 across all states since the outbreak of the COVID-19 pandemic.1 A significant contributor to these gains in coverage is the Families First Coronavirus Response Act (FFCRA) “continuous coverage” requirement, which limits the ability of states to disenroll individuals from Medicaid. Following the end of the federal public health emergency (PHE), states will no longer be subject to this requirement, which could potentially result in widespread disenrollments from Medicaid.

States have a clear imperative to center health equity as they plan for the end of the PHE. Black, Latino/a and other people of color are overrepresented in the Medicaid program and are most at risk of coverage loss. These communities have also experienced the worst impacts of the pandemic, with Black and Latino/a individuals more than twice as likely to have been hospitalized or to have died as a result of COVID-19.2

Background

Passed by Congress in March 2020, FFCRA was intended, in part, to shore up state finances by temporarily increasing the federal share of Medicaid funding for states. To protect health coverage during the pandemic, states were prohibited from disenrolling individuals from Medicaid for the duration of the federal PHE as a condition of accessing the enhanced funding. This continuous coverage requirement extends from March 18, 2020, through the end of the month in which the PHE ends.3 In January 2021, the Biden administration announced that the PHE will likely remain in place through the entirety of 2021, meaning the continuous coverage requirement will likely remain in effect at least through the end of this year.4

Following the expiration of the PHE, states will resume normal eligibility and enrollment activities and begin to redetermine Medicaid eligibility for all enrollees. The Centers for Medicare & Medicaid Services (CMS) has released guidance that attempts to mitigate coverage disruptions by giving states 12 months to complete the “PHE unwinding” process and requiring robust consumer communication, among other strategies.5 But there is still considerable risk of coverage loss following the end of the PHE due to the coverage churn that is so prevalent in Medicaid.

Implications of the End of the PHE for People and Communities of Color

Large-scale disruption in health coverage as a result of the expiration of the federal PHE will have a disproportionate impact on Black, Latino/a and other people of color, who are significantly overrepresented in state Medicaid programs. Even before the pandemic, long-standing, structurally racist policies and practices in the United States had created an environment where Black, Latino/a and other people of color experienced a significantly greater degree of volatility in employment, income and housing. These conditions will exacerbate the coverage impacts at the end of the PHE.

Black, Latino/a and other people of color have borne the worst economic impacts of the pandemic. While the unemployment rate in 2020 increased by only 1.8 percentage points for white individuals, it increased by 3.2 and 3.5 percentage points for Black and Latino/a individuals, respectively.6 Additionally, recent Census data suggests that the pandemic has only exacerbated housing instability among people of color.7

These economic and housing impacts put Black, Latino/a and other people of color at disproportionate risk of losing their health coverage at the end of the PHE. Changes in circumstances related to employment, income and housing heighten the risk of individuals losing coverage due to churn. Medicaid agencies will face greater challenges in accessing the necessary income data to automate eligibility redeterminations for individuals with volatile employment situations, as well as in locating individuals who have moved or are newly homeless. In addition, individuals experiencing employment changes face greater challenges in verifying their incomes.

Centering Equity in Planning for the End of the PHE

The unwinding of the federal PHE—and the potential for coverage losses—are a looming health equity issue. States can deploy a variety of strategies to maximize coverage retention, including:

  • Launching a robust communications plan to leverage paid media, social media, consumer noticing and partnerships with community-based organizations to spread the word about upcoming Medicaid renewal requirements;
  • Engaging through a community-based approach with trusted messengers and community-based assisters to do outreach and assistance;
  • Leveraging managed care plans to engage in outreach and assistance activities through a community-based approach;
  • Collaborating with and funding navigators and assisters for outreach and renewal assistance;
  • Updating state IT systems to leverage the widest possible range of data to automate renewals;
  • Ensuring that paper forms are only used when required and are simple and pre-populated;
  • Employing a broad outreach strategy and identifying opportunities to update address information; and
  • To the extent they are found ineligible for Medicaid, ensuring that individuals are transferred to a state-based marketplace or Healthcare.gov for subsidized Marketplace coverage.

Robust and immediate planning efforts by state and federal leaders are critical for ensuring that the end of the PHE does not exacerbate already widespread racial and ethnic disparities in the American health care system. At the same time, efforts to improve coverage retention post-PHE can have significant benefits for the broader public by improving health care coverage and access for the population overall.


1 https://data.medicaid.gov/dataset/6165f45b-ca93-5bb5-9d06-db29c692a360

2 https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

3 FFCRA § 6008

4 https://ccf.georgetown.edu/wp-content/uploads/2021/01/Public-Health-Emergency-Message-to-Governors.pdf

5 https://www.medicaid.gov/federal-policy-guidance/downloads/sho-21-002.pdf

6 https://www.epi.org/indicators/state-unemployment-race-ethnicity/

7 https://www.urban.org/urban-wire/new-data-suggest-covid-19-widening-housing-disparities-race-and-income

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