What happens when COVID emergency ends?

More than 400,000 Ohioans may lose Medicaid coverage – government-paid health insurance for low-income or disabled people – this summer when the federal government's COVID-19 emergency declaration ends, according to the Commonwealth Fund.

Under the declaration, Ohio and other states were unable to take people off Medicaid, even if they became ineligible. Around 3.3 million Ohioans were enrolled in Medicaid this fiscal year as of February, an increase from around 2.8 million from 2020.

But that declaration is set to end July 15, and many don't expect it to be renewed.

Those who became ineligible will have to be removed from the rolls, which isn't necessarily bad. A person could have climbed the income ladder during the pandemic and is now qualified for other health plans.

But the worry is underfunded and understaffed counties are facing the task of combing through the entire Medicaid population to disenroll ineligible people – all within a 90-day deadline imposed by Ohio Republican lawmakers.

The deadline could cause an overwhelmed system to remove people from Medicaid when they shouldn't be.

"I just see a collapse," said state Rep. Thomas West, D-Canton. "This is going to come very fast and furious... we have 90 days. I can't even imagine that."

A push for speed

Usually, Medicaid eligibility is reviewed once every 12 months, with enrollees being checked on a rolling basis. Current federal guidance recommends the "unwinding" process occur over a little more than a year. The goal is to spread the workload and avoid a crush of everyone renewing their eligibility at once.

But state lawmakers favoring smaller government and cost cutting want it done within 60 to 90 days.

"We want people to move on with their lives and obtain insurance through other means, hopefully through employment," said Sen. Mark Romanchuk, R-Ontario, who chairs the Joint Medicaid Oversight Committee. "We'd like to see the individuals that are no longer eligible for the right reasons... be removed immediately, so we can stop paying money... for an individual that really isn't ever going to require any kind of benefits."

The conflicting directions are leaving county case workers unable to do much in advance. An Ohio Department of Medicaid spokesperson said it's awaiting directions from the federal government on how to proceed.

To help meet the quick deadline, Ohio has improved its automatic renewal capacity, where eligibility is verified based on available data. Up to 57% of cases can be done this way, said Patrick Beatty, the Medicaid department's policy chief.

Following the direction of lawmakers, $35 million was set aside to third-party vendor Public Consulting Group to quickly analyze the rest and identify "likely ineligible" people to process first. PCG did not respond to inquiries, but the databases used are more expansive than a county case worker's, said Joel Potts, head of the Ohio Job and Family Services Directors' Association.

But critics say the PCG contract incentivizes disenrollment, where the more ineligible people it finds, the more money it gets. And if that person is particularly expensive to cover – typically sicker and older – that's more cash.

"We're putting populations who are still, by the way, disproportionately vulnerable to the impacts of the virus, in harm's way," said Loren Anthes, who leads Community Solutions' Center for Medicaid Policy.

Overworked and understaffed

Potts questioned why that $35 million was not given to county job and family service departments instead, which only received $1 million extra this year. Counties still have to process whatever PCG identifies.

Like most of the economy, county departments already face significant worker shortages for positions that require a lot of training. Around 90% of counties are "deeply concerned" with staffing, Potts said.

"We've been working overtime for a whole pandemic," said Michelle Lindeboom, assistant director at Franklin County's department, which lost 50 workers since COVID-19 appeared and used 8,300 hours of overtime this year.

The end of the emergency declaration is expected to significantly increase the workload and number of inquiries. Renewing Medicaid eligibility isn't simple. Contacting Medicaid participants multiple times, making sure documents are correct and dealing with a lengthy appeals process all add time.

Ohio Medicaid estimates counties across the state handle 160,000 total cases a month, but that includes people normally renewing or applying for Medicaid for the first time. The pace isn't enough within 90 days to cover the 43% of people who can't be renewed automatically.

In fact, Potts thinks the full unwinding process could take three to five years.

"I just don't think that is realistic," said Bart Logan, spokesperson for the Franklin County department, when asked if they could meet the 90-day deadline.

Will you lose your Medicaid coverage?

The workload and time crunch have advocates worried a crisis will occur and mistakes will be made. People may not be contacted properly to ensure they renew for Medicaid, or the appeals process for someone kicked off may not be followed through.

"I think your average Ohioan on Medicaid is going to either be confused or scared," said Anthes, the Medicaid policy expert. "Unfortunately, for a lot of people, they're going to have to be looking out for themselves."

The Ohio Department of Medicaid told lawmakers that beyond mail, it would take advantage of phone campaigns, technical upgrades and advocacy organizations to make sure Ohioans renew their eligibility. For those who are no longer eligible, the department will guide them to other health coverage.

Lawmakers are currently waiting on the Medicaid department for more answers on the process. Some indicated they are open to giving counties more resources. Rep. West said he'd support removing the 90-day timeframe, which could provide relief.

But for his GOP colleagues, a longer timeframe wasn't on most of their minds. In fact, some asked if the removal could happen sooner before the end of the COVID-19 emergency.

"We are spending a lot of money on people that are not eligible," said state Sen. Stephen Huffman, R-Tipp City.

Titus Wu is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.