Catherine Rampell: The Great Medicaid Purge was even worse than expected

It's a tale of two countries: In some states, public officials are trying to make government work for their constituents. In others, they aren't.

This week marks one year since the Great Medicaid Purge (aka the "unwinding") began. Early during the pandemic, in exchange for additional funds, Congress temporarily prohibited states from kicking anyone off Medicaid. But as of April 1, 2023, states were allowed to start disenrolling people.

Some did so immediately. So far, at least 19.6 million people have lost Medicaid coverage. That's higher than the initial forecast, 15 million, even though the process hasn't yet finished.

Some enrollees were kicked off because they were evaluated and found to be no longer eligible for the public health insurance program — maybe because (happily!) their incomes rose, or because they aged out of a program. But as data from KFF shows, the vast majority, nearly 70%, lost coverage because of paperwork issues.

These "procedural" disenrollments happened because the Medicaid recipient (or their parent or guardian) never completed the renewal process. Maybe the state sent the notice letter to an out-of-date address. Or maybe social services lost a file. Whatever the case, without ever being reevaluated for eligibility, they were simply purged from the system.

In any other rich country, government failure at this scale would be scandalous. Or at least a little bit embarrassing. Think about it: Government dysfunction has undermined a critical, half-century-old safety-net program. States knew this "unwinding" process would be a massive challenge that could overwhelm their infrastructure, yet they bungled it anyway.

Equally embarrassing: We don't know what ultimately happened to those who were purged and how many have any access to care now.

To their credit, some states did try to rise to the occasion. For instance, Tennessee and Minnesota applied for (and received) lots of federal waivers to help them use more of the administrative data they had on file to automatically renew eligible beneficiaries' coverage without requiring people to fill out yet more paperwork. Some states, such as Kentucky, also delayed eligibility reassessments for some groups.

Some states also learned from their pandemic experience: They realized that not requiring young kids to repeatedly submit the same paperwork reduced the risk of vulnerable children wrongfully losing access to medical care. (Who knew?) Now, a dozen states around the country are working to permanently reduce Medicaid's administrative barriers and allow low-income kids to stay covered for longer periods.

In Washington state, Oregon and New Mexico, for instance, kids have "continuous eligibility" for public health insurance from birth to age 6. This basically means that if they're poor enough to qualify for Medicaid or the Children's Health Insurance Program (CHIP) as infants, they can automatically stay on the program through toddlerhood.

"We've unlocked this flurry of really unprecedented changes to help kids keep coverage," says Joan Alker, executive director at Georgetown University's Center for Children and Families. "That's the good news. The bad news is that some states have moved really aggressively to push people off their [Medicaid] rolls."

In some parts of the country, public officials are slashing bigger holes in their safety nets. In Arkansas, officials brag about "right-sizing" their state's Medicaid program. This included purging 25,000 children off of "newborn" coverage over the course of six months. More recently, Gov. Sarah Huckabee Sanders-R, announced that Medicaid will not be available to Arkansas moms for the full year after they give birth, as nearly every other U.S. state allows. (Arkansas, by the way, bans nearly all abortions and has the highest maternal mortality rate in the country.)

Florida has likewise opted not to use any of the tools the feds are offering to help limit or slow coverage losses; about one-third of Floridian beneficiaries up for renewal so far have lost their coverage. But that's nothing compared with Texas, where half of those up for renewal were purged.

The Biden administration has tried to limit the damage. At one point, it forced some states to pause procedural terminations when numbers looked suspiciously high, reinstating coverage for about 500,000 people. Recently, the administration also extended the open enrollment period for individual marketplace plans to give people more coverage options.

As bad as the numbers are, it's worth considering how much worse this catastrophe might have been with different federal leadership. Recall that the Trump administration, for instance, did all it could to limit outreach and open enrollment for marketplace plans. It also tried to cut Medicaid coverage more directly.

About 1 in 5 Americans is on Medicaid. Yet, for some reason, the partial dismantling of this critical program has barely pierced the election news cycle so far. Presumably, some politicians would prefer to keep it that way.

Email Catherine Rampell at [email protected].