Editor’s note: This story is being co-published with Sick Note, Libby Watson’s newsletter about America’s nightmarish health care system. Daily Poster supporters can subscribe to Sick Note for 15 percent off by clicking here.

Since the start of the pandemic, Medicaid, the federal and state program to provide health insurance to low income Americans, has been far more generous than in the past. Enrollment is higher than ever, at 77.8 million.

This isn’t because of some nationwide change of heart in state governments; it’s because states were paid to stop cutting people from their Medicaid rolls. Under the Families First Coronavirus Response Act, the first coronavirus relief bill passed in March 2020, states received a 6.2 percent boost in federal Medicaid funding in exchange for halting disenrollments.

The usual process of conducting “redeterminations,” in which states redetermine whether a beneficiary’s income levels or other factors still qualify them for Medicaid, has been paused for almost two years. States can still conduct these checks, but they can’t cut off anyone’s Medicaid until the end of the public health emergency (PHE) the federal government declared at the beginning of the COVID-19 pandemic.

But when the PHE finally expires, states will once again be allowed to remove people from Medicaid rolls. State governments will even be incentivized to do so, because the additional federal money to pay for all those extra enrollees will expire just 60 days after the PHE ends.

Adding to this pressure is a right-wing campaign pushing to end the PHE and calling on states to start disenrolling people immediately, even before the PHE ends. Republicans in the Senate passed a resolution to end the PHE last week, with Sen. Roger Marshall (R-Kan.) saying the powers it granted the government “are no longer necessary.”

The PHE is likely to continue until July or later, but could end as soon as April. That means that even though the Centers for Medicare and Medicaid Services (CMS) has given states up to 14 months to resume redeterminations, states are likely already preparing to slash their Medicaid rolls enough to offset the coming loss of federal funding.

The potential scale of this mass disenrollment could be huge: The Urban Institute estimated in September that up to 15 million people could lose their Medicaid coverage when the PHE ends. The Georgetown Center for Children and Families estimated in a report released in February that 6.7 million children are likely to lose coverage. Many of the new enrollees over the past few years will genuinely no longer be eligible — not a surprise, since the income limits for Medicaid are very low — but many others who are eligible will lose coverage anyway.

Bad Incentives

In the United States, most public programs ostensibly designed to help people are difficult to access. Onerous means testing requirements, limited availability, or just plain underfunding all limit access to the social safety net. Of every 100 families with children in poverty, for example, just 21 are on the federal cash welfare program.

Medicaid is no different. In 2020, a quarter of uninsured people, or roughly 7 million people, were eligible for Medicaid but remained uninsured. Why would anyone choose to be uninsured in a country where a medical emergency can bankrupt you, if they could get Medicaid? They don’t: They lose insurance when their income increases, or due to administrative barriers. Simply missing a piece of mail can lead to losing coverage very quickly.

Under non-pandemic circumstances, it’s extremely common for eligible people to lose Medicaid because of administrative hurdles. If the state needs more documentation from a beneficiary, the state only needs to provide a minimum of 10 days to respond to a letter. If they don’t provide the right document in this short time — often less than the amount of time it takes for a letter to even arrive — their Medicaid can be cut off. States can take steps to conduct eligibility checks using their own data, such as quarterly wage reports, but automatic renewals that involve no input from beneficiaries make up a small minority of all renewals; some states will ask people with no income to prove they have no income.

Usually, these redeterminations happen on a rolling basis, depending on the date a beneficiary signed up. Now, states are going to have to determine the eligibility of everyone on their rolls at once. (States must conduct redeterminations after the end of the PHE before disenrolling any beneficiaries, according to CMS guidance.)

States will have a huge administrative task on their hands combing through their Medicaid rolls to find potentially ineligible people. Some states have already begun seeking extra help from private contractors, who stand to make millions from this process. Those contractors will provide call center support, or help states identify potentially ineligible people — all for the goal of reducing the number of people who have health insurance.

A number of circumstances are creating an ideal environment for a contracting bonanza. At the most basic level, there is simply a lack of staff to perform all of these redeterminations, due to chronic underfunding and understaffing of state Medicaid departments.

At a January meeting of the Medicaid and CHIP Payment and Access Commission (MACPAC), a federal commission that reviews state policies and provides recommendations to Congress, the panel heard from a Texas-based Medicaid advocate that Republican Gov. Greg Abbott’s five percent across-the-board budget cut has put “an extreme strain” on the eligibility workforce. In Florida, the governor’s budget for next year included only one extra staff member for the Department of Children and Families, according to Florida Politics — a 0.01 percent increase in staff. In Missouri, as of last month, there were more pending Medicaid applications than current enrollees, and the wait time for approval was 70 days — almost a month longer than the federal maximum of 45 days.

Even in less aggressively underfunded states, the length of the pandemic and staff turnover, especially in the current tight job market, mean that many eligibility workers are simply too new to know what they’re doing. Jeff Nelson, who leads the Utah Department of Health’s Bureau of Eligibility Policy, told MACPAC that he estimates a fifth of their total workforce has never done a redetermination.

There’s also the funding mismatch. Once the PHE expires, states will only have extra funding through the end of that quarter — which means July if emergency declaration expires in April, or September if it’s extended until July, and so on. States can’t start disenrolling people until the first of the next month after the PHE expires.

This gives states just 60 days to disenroll ineligible people before they start having to pay for those enrollees themselves. (The Biden administration has said it will give states 60 days’ notice before they end the PHE; Medicaid directors and other advocates recently asked for Congress to increase that number to 90 days.)

Nelson told MACPAC that this short period of extra funding “does put additional pressure on a state like mine to say, ‘So can you do it in six months? How about three?’” Many states have surpluses, thanks to the booming economy and federal aid, but both Republican and Democratic-controlled legislatures seem more likely to direct that money towards tax cuts than keeping people on Medicaid. The American Prospect recently reported that there is “a historically high number of proposals” to cut taxes across the country.

Nationwide failures to boost Medicaid funding would be wonderful news to the Foundation for Government Accountability (FGA), a conservative dark money group pushing to slash the Medicaid rolls.

FGA is best known for paying for government officials across the country to attend a conference in Disney World, where they encouraged the officials to restrict access to programs like food stamps with work requirements. The organization and its sister group, FGA Action, have received at least $3 million in recent years from the conservative dark money network led by Donald Trump’s judicial adviser, Leonard Leo.

FGA senior fellow Scott Centorino wrote last month for the Washington Examiner that the continuous Medicaid coverage requirement was a “crisis” and a “scandal,” arguing that the generosity of keeping everyone on Medicaid is causing the supposed “worker shortage.” Two other employees of the organization wrote a similar piece for the New York Post.

A recent FGA paper makes the case — using incorrect statistics and estimates — that states should simply opt out of the extra funding and begin disenrolling people immediately. They claim that 90 percent of current Medicaid enrollees are ineligible, providing no source other than “authors’ calculations.”

The actual number is closer to 10-15 percent, according to Tricia Brooks, a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

On a February 17 press call discussing the release of their report on the potential for loss of coverage among children, Brooks said that while renewals conducted without input from beneficiaries “are a good thing when you are using current data sources that are reliable,” states must be “mindful of the kinds of [data] discrepancies that don’t necessarily impact eligibility.” If the state has more nefarious aims, these data searches can be used “intentionally as a way to reduce their enrollment numbers.”

If you’re a state Medicaid director, the experience of states like Missouri, where mismatched data led to erroneous disenrollment, could be either a warning or a roadmap — depending on your ideology.

In some states, there won’t be an opportunity for the legislature to increase funding or find other ways to address the coming wave of redeterminations before it happens, because many legislatures aren’t in session most of the time. In Oregon, lawmakers are frantically trying to pass a bill that would ease the transition, or provide a “bridge” of coverage for enrollees who no longer qualify, before their legislative session ends on May 27. The state has also applied for a federal waiver that would allow them to determine eligibility only once every two years, instead of annually, as currently required by law.

The state’s Medicaid director told MACPAC in January that he wasn’t optimistic that the legislature would act in time: “I have one bite at the apple to get any budget issues resolved, any policy changes resolved, and I don’t think we are going to be able to because things are too fluid.”

That fluidity is cutting into an already tight window for making the necessary changes to the program. “Even just reprogramming the computer system to do its renewals” can be a challenge, Brooks said in an interview last month. It can take four to six weeks to get a change to IT systems in a programming queue, she said, which is already over half of the 60-day window states will have before the extra funding runs out. Every state has its own system to update. A Commonwealth Fund blog post last year argued that states updating their electronic renewal processes to maximize automatic renewals without needing input from beneficiaries is “the most important single step states and CMS can take to avoid coverage losses.”

States know this huge administrative task that will cost millions of dollars is looming, but they don’t know how soon, or how much notice they’ll get. They can’t easily get more money for staff from the legislature, and even if they could, training that staff to conduct redeterminations is time-consuming. And the longer it takes to do all this, the more it costs them.

It’s no wonder, then, that savvy contractors have been able to pitch themselves as the solution to this problem.

Contracting Gold Rush

In the state of Ohio, a $35 million contract with Boston-based consulting firm Public Consulting Group (PCG) will help the state identify people who are potentially ineligible for Medicaid. The company gets more money from the state the more ineligible people it finds; the company can’t kick people off Medicaid themselves, but will provide lists to the state.

PCG has a neat pitch for this setup on their website, which notes that this work can be done “at no cost” using federal funds from the Coronavirus Aid, Relief, and Economic Security (CARES) Act — or they can pay for it themselves, with just “a nominal portion of cost savings” generated by cutting off enrollees.

According to the Ohio Joint Medicaid Oversight Committee’s monthly newsletter from last November, PCG will “work with third-party data sources” like credit reporting agencies to “conduct data matches to identify Medicaid enrollees who are likely ineligible for benefits.” The operating request to the state Controlling Board, which approves funding requests outside the state’s annual budgeting process, claims the company expects to save the state $500 million by identifying up to 400,000 ineligible people, which would represent about 12 percent of Ohio’s total Medicaid population.

Brooks, from Georgetown, said last month that states have to “bear responsibility to monitor these vendors,” and not just use them as “a way to cut people off.” Response rates are low when states request more documentation or information from enrollees, and this leads to eligible people losing coverage — so a state that wanted to cut people from Medicaid would benefit from finding the flimsiest pretext to require someone to reverify their eligibility, like a minor mismatch in data. There’s no information about how PCG will use credit reporting to identify ineligible people, for example, before the state sends out requests for documentation. It’s up to the state of Ohio how thoroughly they want to check PCG’s work.

FirstSource, a consulting firm based in India, has a page on its website pitching its “modular Medicaid Redetermination solution,” which it says “blends digital engagement with proactive outreach.” The company promises improved outcomes “within 30 days of implementation,” and even claims to use “Intelligent Automation” to track individual applications. The company also has a large debt collection business, which it contracts out to hospitals, too.

One company that has already snagged contracts for the redetermination process is also notorious for mistakes and allegedly mistreating its workers: Maximus.

In 2020, Maximus lost a contract for handling Medicaid eligibility in Kansas due to poor performance. Its workers, represented by the Communications Workers of America labor union, have complained about COVID outbreaks in the office; workers for the company earned as little as $10.80 per hour, according to a 2021 report. Maximus is even featured in a Netflix documentary about a case where one of their social workers failed to report cigarette burns on Gabriel Fernandez, a child who died as a result of abuse from his mother and her boyfriend.

Like FirstSource and PCG, Maximus’ website has a pitch for states for products to help restart Medicaid redeterminations, complete with imaginary characters in state government who need their help; “Tina” has “only a 12-month window for her team to redetermine benefits,” so “adding Maximus’ knowledgeable professionals could make all the difference.” How nice for Tina.

In their most recent earnings call, Maximus CEO Bruce Caswell said that the “current conditions” had “enabled states to become more comfortable with and desire contracting with a partner like Maximus.” The company’s chief financial officer, David Mutryn, described the pause in disenrollments as “only delays to resuming the core work, recognizing that the redeterminations are really a fundamental part of the Medicaid programs.”

In at least some states, these pitches are working. In New Hampshire, which has contracted with Maximus for years, the state legislature last year approved a $2 million contract with Maximus to provide call center workers, taking calls from the public with inquiries about benefits and redeterminations. The contract was approved last August, with the assumption that the PHE would end soon after.

That was more than six months ago, and disenrollments are unlikely to resume until at least August this year — well after the contract ends in June 2022. The governor’s initial request to his executive council stated that the contract would be paid for with federal money — including money from the American Rescue Plan Act, Joe Biden’s signature coronavirus relief package.

Call center wait times are a crucial metric for how the state is handling the disenrollments, according to Brooks; longer wait times lead to more people abandoning the call, and with that, their ability to reach someone who can help them stay on the program.

Much of the time, contracted call center workers like those at Maximus can’t even do much except answer basic questions. A Medicaid eligibility worker in New Hampshire told me that “the idea that they’re saving us time by taking these calls has been a total disaster,” because “they have very limited access” to the state’s systems. Most callers need help from someone who actually works for the state.

In Arkansas, the state approved a $29 million contract with Maximus late last year — partially to assist with the redetermination process, but also to help with the state’s huge backlog of Medicaid’s applications, which stood at roughly 50,000 in mid-November. Under that contract, Maximus will “recruit, hire, and train contracted eligibility specialists to support the clearing of the Medicaid application backlog and to support the Department of Human Services with staff to process ongoing cases to avoid further increase of the backlog,” according to the state’s Legislative Council, which approved the contract.

When states introduce new ways to make it harder to get or stay on Medicaid, Maximus is there to make money.

In 2015, Arkansas hired Maximus to collect premium payments from Medicaid recipients. Since there was no penalty for failing to pay these premiums, the state earned very little from the program. The only real benefit of this program went to Maximus: Mother Jones reported that “for every $1 the contractor collected from clients, it earned $21.”

In New Hampshire, Maximus won a contract to help the state implement work requirements for Medicaid recipients, providing call center staff to notify beneficiaries. This once again proved a poor investment: The Urban Institute noted in a 2020 report that “less than 10 percent” of people contacted by Maximus answered their phones. These calls cost the state $108,723. The work requirements were suspended in July 2019, and the Biden administration revoked the permits allowing states to impose work requirements in 2021.

What Lies Ahead

There is precedent for the type of mass disenrollment we’re about to see, though nothing on this scale.

As recently as last year, when the federal government reversed a decision to allow Utah to stop charging Children’s Health Insurance Program (CHIP) premiums and the state began disenrollments again, 41 percent of enrolled children lost coverage “almost overnight,” according to Nelson’s testimony to MACPAC. In Missouri, changes to how the state conducted its redetermination in 2018 led to tens of thousands of people, the majority of them children, being kicked off the program.

In Tennessee, a similar change led to at least 220,000 children losing or being at risk of losing coverage from 2016 to 2018, solely due to missing or incomplete paperwork. The company that was contracted to conduct these redeterminations was Maximus. The form that Maximus mailed to enrollees whose eligibility could not be automatically determined was 49 pages long; according to the Tennessee Justice Center, many enrollees lost coverage when they filled out the forms. In one case, a Maximus staff member approved an 8-year old boy’s Medicaid under the category for a pregnant person, not a child.

What’s most disturbing about all of this isn’t what we know, but what we don’t know. Despite several stories from major national outlets on the coming wave of Medicaid cutoffs, there has been little reporting on what, specifically, states will do to ensure people keep coverage — even huge states with millions of beneficiaries, from Texas to California. Will they give recipients longer to respond to documentation requests? Will they conduct more proactive outreach to beneficiaries? Will they pay for advertising campaigns, or provide more translation services for non-English speakers? These are the questions that must be answered in every state, but few are even asking them in the first place.

When the PHE ends, and states suddenly have millions of dollars less to pay for the largest number of Medicaid recipients ever, you can bet that some will choose the most aggressive methods to disenroll people as quickly as possible. Or maybe they’ll just pay someone else to do it for them.

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