An unwinding disaster
An unwinding disaster
It’s worst in red states, but needs a national fix
Welcome to a Friday evening edition of Progress Report.
The world constantly feels like it’s on fire, literally and figuratively, but so many of our political obsessions, the stories we watch on cable news and obsess over on Twitter (I’m not calling it X), wind up being passing flares that leave little mark. At the same time, there are technocratic policy decisions that are being made around the clock, with little public awareness, that wind up shaping the lives of millions upon millions of Americans, and sometimes even change the course of history.
In tonight’s newsletter, we’re exploring the latter — imagine if I led this thing off by saying this issue of the newsletter is going to be ultimately irrelevant in a short time from now! — and then tomorrow, I’ll be back with a new edition filled with good news from around the country.
Now, quickly, before we get to the meat of tonight’s newsletter, check out my latest piece for More Perfect Union. It’s an investigation of sorts into Starbucks’s latest anti-union scheme, this one being carried out by one of the most contemptible corporate conservative front groups in the country. Yes, that’s me hosting. A bit rusty, but I’ll get there.
The Medicaid unwinding process has spiraled so wildly out of control in some states that the federal government is being drawn further and further into the maelstrom.
The federal Center for Medicare and Medicaid Services this week sent a letter to the Florida health authority, expressing deep concern over the state’s rapid purge of Medicaid enrollees: More than 400,000 Floridians have been purged from the low-income health benefit since April, including 130,000 children.
The letter also raised the alarm over how little Florida has done to help families that have attempted to submit the paperwork required to renew their coverage.
“Based on your state’s data, CMS has concerns that your average call center wait time and abandonment rate are impeding equitable access to assistance and the ability for people to apply for or renew Medicaid and CHIP coverage by phone and may indicate potential non-compliance with federal requirements applicable to eligibility redeterminations under title XIX of the Social Security Act,” the federal agency wrote.
In Florida, the average call center wait time is 32 minutes, long enough that 38% of callers give up before even getting an answer. The wait time for Spanish speakers is north of two hours, and in one study, 30% of Spanish-speaking callers were disconnected before they ever spoke to a representative.
In New York, by contrast, the average wait time is zero minutes, while it’s one minute in New Jersey.
Additionally, at least 10% of families applying or reapplying to Medicaid after being purged in Florida are not receiving an answer from the state within 45 days. That delay violates federal guidelines and leaves thousands of eligible people hanging without access to medical care.
Continued non-compliance could lead to federal intervention, CMS warned in the letter, though no specific consequences were threatened.
“It’s shocking,” Stan Dorn, a health policy director the Latino civil rights organization UnidosUS, said recently. “Two-thirds of all children in Florida rely on Medicaid. You would think a top priority would be to make sure parents can reach someone and renew their children’s coverage.”
According to Katie Rodgers Turner, the executive director of the Family Healthcare Foundation in Florida, the state makes things even more complicated by shunting the purged into its outrageously expensive and largely useless catastrophic care program, which it touts as an answer to Medicaid expansion without providing any of the benefits.
The Medically Needy Share of Cost program has monthly deductibles that are usually based on household income, but that can and does vary wildly, especially for those dropped into by default.
“If the family has not actively reapplied, cost will be based on what Florida Department of Children and Families have access to,” Rodgers explains. “It could be thousands of dollars, usually something that's not affordable — $1500 to $6000 for a deductible every month.”
Yes, the deductible resets every month, making the plan only useful in the most catastrophic circumstances, and even then, it’d sap enrollees of their savings. The state does provide some ACA information to the disenrolled, but far back in the packet that hardly anybody receives in time.
The broader issue of cruel indifference is not unique to Florida. The federal government sent letters to every state health authority this week, each reflecting the states’ performance thus far. In far too many instances, the letter included alarming statistics and subtle warnings about consequences for ongoing failure.
Red State Sickness
Nearly five million working Americans have been kicked off of the low-income health care program since April, when states were permitted to remove enrollees for the first time in three years. More than 75% of those purged from Medicaid thus far have lost their health coverage not because they were determined ineligible for the program, but instead due to “procedural problems,” which generally means problems with peoples’ re-enrollment paperwork.
Instead of a failure of bureaucracy, the procedural problems have largely been the product of intentional sabotage. There are now 44 states and DC that have begun the redetermination process, and it’s become clear that many GOP states are using what was supposed to be a careful process to rip gigantic holes in their social safety nets.
In Texas, where 20% of the state was enrolled in Medicaid as late as March, the purge has been even worse than what’s transpired in Florida. By mid-July, Texas authorities had stripped health coverage from around 560,000 people, 80% of whom were disqualified due to those dreaded procedural issues.
Unreliable broadband, low public awareness, and minimal effort by the state have all made it particularly difficult for working class Texans to keep up with their cases and submit information as required. The same problems plague working people in Arkansas and Oklahoma, each of which has bounced 300,000 enrollees since April.
The school year has already begun in much of the South, and as the weeks wear on, the consequences of the purges will become more obvious. Even in states that haven’t expanded Medicaid, there are more government-sponsored and subsidized insurance options available to children, which are supposed to mitigate the damage of the purges.
Unfortunately, it’s hardly working out that way; while 130,000 children have been stripped of Medicaid coverage in Florida alone, the state’s CHIP program, designed for kids from low-income homes, grew by only 6,000 enrollees. Schools breed germs and sickness, and too many kids aren’t going to be able to see a doctor.
So what can be done?
Florida responded to the CMS letter by accusing federal government of targeting red states, which is an admission as much as an allegation. In late June, CMS acknowledged that it had placed temporary pauses on redeterminations in a dozen states so that they could catch-up with backlogs, get in touch with beneficiaries, and restore coverage for the wrongfully terminated. The agency did not name any of those states at the time, but Florida’s reaction eliminates some of the mystery.
The federal government has generally not intervened with how states run their Medicaid programs, even though it pays for much of it. That tradition needs to be set aside right now, as millions of families lose access to care, especially with the fall and a supposed Covid spike on the way. The government set up health navigators to help people sign up for Obamacare marketplace in the earliest days of the ACA, it should be doing the same as the purge continues.
The government also should be sending contacting those removed from Medicaid for any reason and providing personalized resources about ACA subsidies and other alternatives.
The moral imperative in securing healthcare for children and working class adults is obvious, and that should be enough to drive government policy on its own. But because that’s rare, the political imperative is also important to explore.
Medicaid is far from perfect — qualifying for the program means that someone is either unemployed or making almost poverty wages, and because it provides lower payouts for doctors than other insurance policies, many providers either limit the number of Medicaid patients they’ll accept or refuse to accept it altogether. At the same time, between the record 95 million people that were enrolled in Medicaid this April and the 65 million Americans on Medicare, the two programs provided health insurance to nearly half of the American public, creating the closest thing that the United States has had to a broad national public insurance program.
The lack of any redetermination process essentially eliminated annual means testing, and even many hospital systems were becoming increasingly desperate for the Medicaid expansion to arrive in their markets. Normalization was at hand, which explains Republicans’ eagerness to end the three-year pause on eligibility assessments and throw as many people off the program as possible.
This played out last year with the Child Tax Credit, which Republicans were very happy to see killed by Sen. Joe Manchin, a singularly stupid politician, and the year before with the expanded unemployment benefits passed as part of the emergency Covid spending bills. They knew that the longer that government benefits last, the harder it is to mislead the public into believing those benefits they are bad for the broader economy, much less take them away from people. It’s why Republicans still get crushed for even whispering about cutting Social Security.
Aside from subsidies for private ACA policies, accessible Medicaid is the last remnant of the Covid-era safety next expansion, the collapse of which continues to drag down people’s experience of what data indicates is a very solid and growing economy. The Biden administration may crow about the better pay at new solar energy sites, but most jobs are non-union and benefits are scarce. Wages have lagged behind inflation, but not having to worry so much about the cost of health insurance helped to neutralize that issue, even if it wasn’t so immediately obvious.
ACA open enrollment this fall should help to some degree, but I wouldn’t overestimate that. A full three-quarters of people losing Medicaid are doing so because they haven’t received paperwork, don’t have time to parse its complications, or don’t have access to help. The idea that most will be able to hop online on their own accord with their tax subsidies handy and enroll in private insurance is Beltway brain to the extreme. The White House should instead assume that if they don’t take serious action soon, somewhere around 15 to 20 million additional Americans will be without health insurance months into an election year.
Governors like Ron DeSantis and Greg Abbott need working people to be broke and angry, and using federal government policy to strip them of health care and force them into medical debt is a way of sustaining the resentment that fuels their careers. The Medicaid unwinding plays right into the hands of conservatives and their politics of depravity and cynicism. Kids go sick, adults flail and fume, and the far-right benefits. A strong response by the federal government, including a pause on redeterminations, strong guidance to other options, and new rules passed through CMS to ease re-enrollment, are both morally and politically necessary.
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It is shocking. But you know what's also shocking? That "two-thirds of all children in Florida rely on Medicaid." Maybe we need a whole new health care system? Just a thought!