Medicaid expansion debate takes twist: The end of one emergency could trigger another in Kansas

Kansans are used to a particular kind of debate over Medicaid expansion.

Lawmakers in the Sunflower State have scrapped for years over whether to take advantage of a provision in the Affordable Care Act allowing states to expand the health care program covering low-income residents to those making 138% of the federal poverty level.

Democrats and some Republicans have pushed for Kansas to join 40 other states in doing so, while conservatives have pushed back over cost estimates, among other concerns. While the issue hasn't gotten much traction in the Statehouse recently, it was a prominent feature of the 2022 governor's race.

But a lesser-known feature of the COVID-19 pandemic has prompted a different kind of Medicaid expansion, thanks to the ongoing public health emergency, declared in 2020 due to the virus and renewed regularly by President Joe Biden's administration ever since.

The federal government has required states not kick individuals off Medicaid during the public health emergency, a mandate that dates back to the early days of the pandemic.

But when the emergency eventually ends, expected to be some time in 2023, there is certain to be a deluge of individuals whose eligibility for Medicaid the state will have to determine. And research points to a heightened risk that this process will leave many without coverage — potentially over 100,000 individuals.

"We know the pandemic caused people to stop going to health care for a little while," said Alice Weingartner, chief strategy officer for Community Care Network of Kansas, a group representing the state's federally qualified health centers and other health clinics. "And now we're at the point where people are starting to really seek their care or seek treatment for things that they maybe didn't acknowledge before. We want that to continue. We want people to stay invested in their health."

End of public health emergency could impact 125,000 Kansans

When lawmakers converged in Washington, D.C., in April 2020 to pass the first of what would be many COVID-19-related aid packages, many observers focused on provisions in the bill that expanded unemployment benefits, food stamps and required insurance coverage of COVID-19 testing.

But also included was the ability for the federal government to pay an increased share of Medicaid costs, with expenses related to the program generally shared between the state and federal government. Such a move often occurs during economic downturns, when the number of individuals on the Medicaid rolls can swell due to financial turmoil.

In exchange, states had to keep individuals continuously enrolled in Medicaid, preventing them from booting residents off the program if they became ineligible. This also designed to reduce the burden on individuals who should remain covered but struggle to prove their eligibility, a process that often creates an array of bureaucratic hassles.

Nationally, this has grown the number of individuals covered by Medicaid substantially. Data from the Kaiser Family Foundation shows 18.7 million more people enrolled in Medicaid nationwide when compared with February 2020.

This has also been true in Kansas. Pre-pandemic, 405,716 individuals were enrolled in KanCare; as of September, that number has grown to over 528,000.

Tanya Palmer, director of eligibility for KanCare, told lawmakers at a hearing earlier this month that it was expected between 100,000 and 125,000 individuals could lose coverage when the emergency ends.

Some of these individuals are simply no longer eligible for KanCare but were preserved from being kicked off during the pandemic because of the health emergency.

But others could be victims of a phenomenon known as "churn," where individuals are disenrolled and then re-enrolled in a short period of time, causing a coverage gap.

This can happen for a variety of reasons. Sometimes a person temporarily makes too much to qualify for Medicaid. Other times they encounter hurdles in re-enrolling, such as missing a notice in the mail or even running into problems that require phoning the program call center.

To understand how big of a problem churn poses, a U.S. Department of Health and Human Services study shows that 45% of individuals nationally who will lose coverage would remain eligible. For children, that number is 72%.

"It could double the number of uninsured children in this country," said Tricia Brooks, a research professor at the Georgetown University McCourt School of Public Policy's Center for Children and Families.

While losing coverage for any length of time can have an adverse impact on adults and children alike, the impact on younger Kansans is greater, said Heather Braum, heath policy adviser for Kansas Action for Children.

Not having health insurance means missing well-child visits, routine treatments and screenings and even childhood immunizations.

"Whether they get care can affect the trajectory of their lives," Braum said.

Kansas forced to juggle logistical hurdles with mass Medicaid renewals

The end of the Medicaid protections would also create a significant logistical hurdle for states, who already do not always handle new applications in a timely manner.

KanCare data, for instance, shows that 352 applications currently pending had not been processed within the federally required 45-day window, about 8% of open applications. Other states, like Missouri, have had an even worse rate.

Now the state will have a deluge of eligibility determinations to make, after months of not having to do so.

To attempt to manage volume, the state is taking the federal government up on a provision to spread the determinations out over 14 months, rather than attempting to tackle them in a much more compressed timeframe.

Still, there is an understanding that the state's infrastructure could be strained. Hiring workers for the state's call center, which is run by a third-party contractor, has remained a struggle, for instance.

"Not only do we need to boost capacity, because this is going to be a much larger volume of transactions that have to occur than have ever occurred before," Brooks said. "But it comes at a time when states are challenged in recruiting and retaining employees."

And states vary in how prepared their information technology setup is to cope.

Kansas, for instance, automates relatively little of its renewal process. In some places, the bulk of renewals are ex parte, where an individual is notified of their status automatically based off information already provided to the agency. In Kansas, fewer than 25% of all renewals are ex parte, increasing the demand on human workers.

But experts say the state has also undergone needed technology improvements in recent years, including a long-desired move to allow individuals to renew and check the status of their accounts online. Lawmakers report fewer complaints from weary constituents as well.

"The system that you're using must be working a lot better because we haven't had, knock on wood, anyone that frustrated, the way it was before," said Rep. Barbara Ballard, D-Lawrence. "And that is a huge improvement."

And Palmer, the KanCare director of eligibility, said the agency was emphasizing outreach to individuals enrolled in the program to encourage them to ensure contact information was up to date, thus increasing the odds that crucial information on renewals would get to their intended destination.

Other entities are also planning their own messaging and outreach.

The state will be spreading the renewals out over the entire 14-month period, meaning Weingartner, of Community Care Network of Kansas, said it was imperative that her group and others spread the message early and often — but also that it doesn't get forgotten.

"Some of those things are happening already," she said of the efforts to inform residents. "But it's as we get closer to figuring out when this is truly going to kick off that's when I think you'll see a big lift for that."

Emergency end set to renew debate over Medicaid expansion

The public health emergency won't end in January, after President Joe Biden's administration didn't give providers the mandated 60-day notice of their intent to end the declaration. Many are expecting the emergency to remain in place even longer, until at least April.

Such a move has prompted controversy and even an effort, spearheaded by U.S. Sen. Roger Marshall, R-Kan., to revoke it.

But when the time comes to end the emergency, it will renew a debate that has brewed in Kansas for years on expanding KanCare.

Of those who lose coverage due to no longer being eligible, many will fall into the so-called "doughnut hole," where they make too much money to qualify for Medicaid but too little to qualify for subsidized coverage on the health care exchanges created under the Affordable Care Act.

Gov. Laura Kelly talked at length on the campaign trail of renewing a push to expand Medicaid in Kansas. The last serious push to do so came in 2020, when a deal between Kelly and the former majority leader of the Kansas Senate, Jim Denning, ultimately collapsed after the issue became blended with a debate over abortion.

"We need to bring that money home to Kansas," Kelly said at an Olathe rally days before her victory in the Nov. 8 election. "We need to take care of folks. We need to protect our rural hospitals, and we need to create the 23,000 jobs that Medicaid expansion can do."

Top Republicans have rejected the idea as too expensive and unwieldy, and it is unlikely to advance this session, something even its advocates acknowledge.

"It's tough to get around given leadership positions and that kind of stuff in the Legislature," said Sean Gatewood, co-administrator of the KanCare Advocates Network.

Weingartner said Community Care Network would continue to push for Medicaid expansion — but also noted it would not distract from the very real push to reach individuals affected by the unwinding in the next year.

"The reality is, this is where we are today," she said. "And this is the system we have to work within. And so we want to make sure that we connect with as many people as we can to make sure that they can either maintain their coverage or find some alternative coverage."

Andrew Bahl is a senior statehouse reporter for the Topeka Capital-Journal. He can be reached at [email protected] or by phone at 443-979-6100.