Medicaid watcher warns about social and health impacts of return to ‘churn’

By Judy Stringer / March 18, 2024

Starting in early 2023, Ohio — like other states that took advantage of extra federal pandemic funds in exchange for pausing disenrollments — resumed regular income eligibility checks. Since then, more than 650,000 Ohioans have lost their Medicaid coverage, according to data from the Kaiser Family Foundation.

In social service circles, “churn” is a term used to describe disruptions or gaps in Medicaid coverage. This is a common occurrence that happens when incomes fluctuate — from seasonal jobs, for example — or when otherwise eligible individuals fail to respond to income inquiries or are unable to submit the right paperwork on time.

Much of that churning, however, stopped during the COVID-19 public health emergency. For nearly three years, hundreds of thousands of impoverished Ohioians, including many who lost their jobs during the pandemic, were automatically sustained on the public insurance plan.

As a result, individuals and families who had historically — and understandably — prioritized food and rent over hefty private insurance premiums were freed from making those “tough decisions,” according to Brandy Davis, a Medicaid policy fellow at The Center of Community Solutions in Cleveland.

“Prior to the continuous enrollment provision that existed during the public health emergency, there was an episodic nature to how people accessed Medicaid coverage, which does not promote healthier patients,” she said.

Individuals with interruptions in coverage often delay or forgo care, Davis explained, or leave prescriptions unfilled because they cannot afford them. And the stakes are high when it comes to medical care lapses among low-income households, who already suffer higher rates of mental illness, chronic diseases, such as heart disease and diabetes, and premature death.

In one 2018 University of Michigan study, diabetes patients with insurance coverage gaps of 30 to 60 days were five times more likely to end up in an ER, hospital or urgent care once they regained coverage than their counterparts without disruption.

That’s why Davis and her Community Solutions colleagues are paying particularly close attention to the “unwinding” of that COVID-era “continuous benefit” provision. Starting in early 2023, Ohio — like other states that took advantage of extra federal pandemic funds in exchange for pausing disenrollments — resumed regular income eligibility checks. Since then, more than 650,000 Ohioans have lost their Medicaid coverage, according to data from the Kaiser Family Foundation.

Kevin Gowan, director at Cuyahoga County Job and Family Service, which administers Medicaid funds in the county, said that roughly 44,000 people have fallen off its rolls since the unwinding began. But, he added, the agency is not yet at pre-pandemic levels.

“Prior to the pandemic conditions, in early 2020, we had roughly 385,000 people enrolled in Medicaid in Cuyahoga County,” Gowan said. “Before they changed the rules back, so March of 2023, we had over 460,000 people on Medicaid. Now, we are at about 416,000. … It’s above the pre-pandemic levels but below the pandemic [levels], which is not shocking.”

Gowen emphasized that about half of the renewals in Ohio have been processed electronically, “without the clients having to do anything,” via external databases. The state, for example, has been automatically migrating income data submitted for SNAP (i.e. food stamps) eligibility into Medicaid databases, Davis explained. It also utilized a third-party vendor to mine employment and/or credit records for suspected eligibility matches and partnered with managed care organizations and the U.S. Postal service to update beneficiary contact information.

“The other thing that needs to be understood regarding the renewal process is if you return your packet, that puts a hold on your case until we take action,” Gowen said. “The majority of people who are removed are ones who do not respond to the request for renewal information.”

Winding down

The official pandemic unwinding period is set to expire on March 31. Davis said after that date, Medicaid offices are slated to lose access to many of the external databases and partnerships that helped it process renewals over the last 12 months.

“So essentially, most of the information that was extraneous to Medicaid, besides the information they already collected, will no longer be able to be collected after March 31,” she said.

Davis worries that will mean people who are eligible for these critical benefits might be mistakenly disenrolled. Given the massive number of people who joined Medicaid during the pandemic, “enrollees who do not have experience actively renewing coverage may be less prepared for what to expect when their eligibility is redetermined,” she said.

There are also concerns about children losing coverage because a guardian does not respond, people who have moved or been displaced not receiving their packet and older adults and/or those with disabilities or limited English proficiency not understanding how to respond.

Davis is holding out hope that the federal government will “step in” and “extend some of the flexibilities” that have promoted successful reenrollment practices at the state level.

“These enrollment strategies have proven to be very effective in allowing people who should be on Medicaid to remain covered,” she said. “If people are back to these situations where they are choosing food over prescriptions or spending money on care that takes away from their grocery budget, more people will be in a position to become sicker.”

Paul has recruited Cleveland Ward 15 Council Member Brain Kazy’s help. The two plan to host a July 29 pickleball event at Jefferson Park, where they would like to see the city’s first courts built. The afternoon potluck social will include free lessons, complete with loaner paddles for newbies.

Given pickleball’s low barrier to entry, Paul said, it’s a shame that most of the new public courts (and those in the works) are popping up in suburbs, putting them out of reach for urbanites without a car or those with limited time for leisure activities.

“There’s a lot of talk about health disparities and inequality, and I don’t think it’s crazy to suggest pickleball could play a role in making things a little bit better,” he said. “We just got to keep it fun, and the people will come.”