Medicaid Programs Adjusting to Change During the Pandemic

As the COVID-19 pandemic rages on in the U.S., one constant that many people have come to rely on for healthcare is Medicaid. But that federal-state program is expected to come under increasing fiscal pressure in the days to come, experts told MedPage Today.

“The world’s turned upside down,” Matt Salo, executive director of the National Association of Medicaid Directors, in Washington, said in a phone interview. “Ever since February, Medicaid directors have been ‘all coronavirus all the time.’ It’s completely changed the way everyone is doing business, changing the way healthcare is delivered, and changing the finances — it’s all-consuming.”

Lag in the Numbers

Despite the large numbers of people losing their jobs in the pandemic, Medicaid enrollment hasn’t increased all that much; Georgetown University recently reported that in its survey of 22 states, Medicaid enrollment grew 5% on average from February to May. “There’s always kind of a lag in that enrollment,” Salo said, pointing to a couple of factors. First, thanks to the Affordable Care Act (ACA), people who live in states that expanded the Medicaid program may already be on Medicaid, since it includes those who make up to 138% of the Federal Poverty Level.

In addition, “the pandemic is forcing social distancing not just in everyday life but in healthcare utilization, too,” he continued. “So one of the big factors in enrollment spikes during a downturn is that people still go to the emergency room or go to the hospital for some medical event, and there will be social workers there to do ‘presumptive eligibility’ to get people enrolled,” but during this pandemic, “people aren’t going to the doctor unless it’s an actual emergency, so it’s limiting the flow of people coming in through that doorway.”

Jerry Vitti, founder and CEO of Healthcare Financial, a Quincy, Massachusetts company that connects low-income, elderly, and disabled populations with public benefit programs, is seeing many of his clients defer their care. “We’re in New England, and we’ve been in lockdown a long time and we’re just starting to open up,” he said during a phone interview at which a public relations person was present. “In the Boston area, hospitals are overwhelmed and only doing emergency surgery — no elective surgery — so these services that folks need on a continuous basis, and the support from providers, has been in some ways withdrawn.” Telemedicine is an option, “but a lot of folks don’t have the technology or technical savvy to do a Zoom call with their physician, and their conditions are more complex.”

For some Medicaid beneficiaries, though, telemedicine has really helped, according to Salo. “The silver lining is whenever things get really, really bad, necessity is the mother of invention,” he said. Medicaid programs are “using this opportunity to break through a lot of historical logjams or barriers that kept us from doing a robust telehealth practice. It’s going to potentially help solve a lot of access problems; it reduces the need for transportation — always a challenge — and reduces the need for people to take off a lot of work time.” Salo credited the Centers for Medicare & Medicaid Services with being flexible and easing some of the rules around telehealth, especially health privacy laws that previously prohibited providers from using easily accessible platforms such as Zoom.

Enrollment Expected to Increase

Finally, Salo said, the unemployment trajectory isn’t the same as a normal economic downturn, in which workers are abruptly let go. Instead, people are “put on hiatus, put on reduced hours … People are eased out of full employment and told they’ll be eased back on,” so they’re not necessarily looking for new insurance right away.

According to a Commonwealth Fund survey of 2,271 U.S. adults, 21% of those who had been working full-time in February said they or their spouse had since been laid off or furloughed from their job due to the pandemic. Of those respondents, 41% said they had gotten health coverage through that employer. Among the respondents with the job loss or furlough, 53% said they were still getting coverage through that job, while 21% were uninsured and 14% were getting coverage through their spouse’s job. An additional 7% were covered through an ACA marketplace plan or Medicaid.

Cindy Mann, former director of the Center for Medicaid and CHIP Services in the Obama administration, said she expected Medicaid enrollment to accelerate. “Every single time in the nation’s history since 1965, when people become unemployed, and lose their income and health coverage at the same time, Medicaid enrollment goes up and that’s been consistent through every economic downturn.” It may even be more pronounced this time around, since the ACA’s Medicaid expansion “captures a group of people often at the margins in terms of the workforce,” added Mann, who is a partner at Manatt Health, a professional services firm in Washington.

Will More States Expand Medicaid?

As people continue to struggle with unemployment and loss of health insurance, one question that arises is whether the 13 states that have yet to expand Medicaid will decide to do so. The most recent state to take up expansion is Oklahoma, where voters narrowly approved at the end of June a ballot measure to expand the state’s Medicaid program. “When you ask people through a referendum, they vote for it,” said Vitti. “If you ask the elected representatives and the president, they’re against it because it’s Obamacare, but that shows a gulf between the electorate and the leadership.”

Expanding Medicaid could be an easy fiscal argument to make, said Salo. “On some level you can say, ‘Sure, it might make more sense to think about if we’ve got a lot of people going uninsured and where are they going to go? They’re going to go to the emergency room and stop getting preventive or other visits, so maybe we should take advantage of that 90/10 federal match’ — you could make a terrific argument for that … But fiscal issues are not driving the decision not to do expansion; the decision not to do expansion is almost entirely political.”

In the meantime, Salo and Mann say, the best thing the federal government could do to help states that are struggling with rising Medicaid costs is to increase the federal Medicaid assistance percentage (FMAP) — the percentage that the federal government pays of each state’s Medicaid costs. Early in the pandemic, Congress increased each state’s federal match by 6.2 percentage points, but the National Governors Association and other groups recently wrote a letter urging Congress to raise it to 12 percentage points and to “be retroactive to January 1, 2020, and remain until September 30, 2021, regardless of unemployment conditions.”

“Given the magnitude of both the public health and economic crises the nation continues to face, state and local governments need more support to provide health care services to individuals and families,” said the letter, which also was signed by the National Association of Counties, the National League of Cities, and the National Conference of State Legislatures.