Editor’s Note: This brief was updated on Jan. 31, 2023 to clarify implications related to the end of the national emergency and public health emergency on May 11, 2023.

On Jan. 30, 2023, the Biden Administration announced its intent to end the national emergency and public health emergency declarations on May 11, 2023, related to the COVID-19 pandemic. These emergency declarations have been in place since early 2020, and gave the federal government flexibility to waive or modify certain requirements in a range of areas, including in the Medicare, Medicaid, and CHIP programs, and in private health insurance, as well as to allow for the authorization of medical countermeasures and to provide liability immunity to providers who administer services, among other things. In addition, Congress also enacted legislation—including the Families First Coronavirus Response Act (FFCRA), the Coronavirus Aid, Relief, and Economic Security (CARES) Act , the American Rescue Plan Act (ARPA), the Inflation Reduction Act (IRA), and the Consolidated Appropriations Act, 2023 (CAA)—that provided additional flexibilities tied to one or more of these emergency declarations, and as such they too are scheduled to expire when (or at a specified time after) the emergency period(s) expires.

This brief provides an overview of the major health-related COVID-19 federal emergency declarations that have been made, and summarizes the flexibilities triggered by each in the following areas:

• Coverage, costs, and payment for COVID-19 testing, treatments, and vaccines
• Medicaid coverage and federal match rates
• Telehealth
• Other Medicaid and CHIP flexibilities
• Other Medicare payment and coverage flexibilities
• Other private insurance coverage flexibilities
• Access to medical countermeasures (vaccines, tests, and treatments) through FDA emergency use authorization (EUA)
• Liability immunity to administer medical countermeasures

This is not meant to be an exhaustive list of all federal policy and regulatory provisions made in response to COVID-19 emergency declarations. For example, we do not cover the entire range of federal and state emergency authorities exercised under Medicaid Disaster Relief State Plan Amendments (SPAs), other Medicaid and CHIP SPAs, and other state-reported administrative actions; Section 1115 waivers; Section 1135 waivers; and 1915 (c) waiver Appendix K strategies. The Centers for Medicare & Medicaid Services maintains a more complete list of coronavirus waivers and flexibilities that have been exercised since early 2020; some state actions to respond to the emergency may have expiration dates that are not tied to the end of the federal emergency declarations. This brief also does not include all congressional actions that have been made affecting access to COVID-19 vaccines, tests, and treatment that are not connected to emergency declarations, such as coverage of COVID-19 vaccines under Medicare and private insurance (see Commercialization of COVID-19 Vaccines, Treatments, and Tests: Implications for Access and Coverage for more discussion of these issues).

Overview of Major Health-Related COVID-19 Federal Emergency Declarations

The early days of the COVID-19 pandemic were marked by several emergency declarations made by the federal government, under several broad authorities, each of which has different requirements related to expiration.

• A public health emergency (PHE) was initially declared by the Secretary of the Department of Health and Human Services (HHS) in late January 2020, pursuant to Section 319 of the Public Health Service Act. A PHE lasts for 90 days and must be renewed to continue; the PHE for COVID-19 has been renewed several times, most recently in February 2023, and is currently scheduled to expire on May 11, 2023.
• A national emergency declaration was issued by former President Donald Trump in March of 2020, pursuant to Section 201 of the National Emergencies Act. A national emergency declaration is in effect unless terminated by the President, or through a joint resolution of Congress, or if the President does not issue a continuation notice annually. Such a notice was issued by President Trump to continue the emergency beyond March 1, 2021, and by President Biden to continue beyond March 1, 2022. As announced by the Biden Administration on Jan. 30, 2023, the administration plans to extend the national emergency to May 11, 2023, then end it on that date.
• A separate emergency declaration pursuant to Section 564 of the Federal Food, Drug, and Cosmetic (FD&C) Act was issued by the Secretary of HHS in February 2020. Based on this determination, on March 27, 2020, the Secretary declared that circumstances existed to justify emergency use authorization (EUA) of medical countermeasures for COVID-19. An EUA is a mechanism to facilitate availability and use of medical countermeasures that are determined to be safe and effective but have not yet been formally approved. An emergency declaration issued pursuant to Section 564 of the FD&C Act remains in effect until terminated by the HHS Secretary. The timing to conclude the EUA is to be determined; it will not conclude on May 11, 2023, with the other declarations.
• A declaration under the Public Readiness and Emergency Preparedness (PREP) Act (pursuant to Section 319F-3 of the Public Health Service Act) was issued by the Secretary of HHS in March 2020. This declaration provides liability immunity for activities related to COVID-19 medical countermeasures. Since then, 10 amendments to the declaration have been issued to extend liability protections related to COVID-19 countermeasures. For a PREP Act emergency determination, the Secretary must specify an end date; in this case, it has been set as October 1, 2024, in most cases (although there are some exceptions).

Key Flexibilities Triggered by Major COVID-19 Federal Emergency Declarations

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The 12.5 million people who are jointly enrolled in Medicare and Medicaid include some of the poorest individuals in the U.S. with some of the highest health needs, requiring disproportionately high spending from both programs to support them.

Two new KFF analyses examine the demographics of this population as well as the latest data on program enrollment and spending.  These data can help inform federal and state policy discussions about ways to improve coordination and management of care for these individuals.

These Medicare-Medicaid enrollees — sometimes referred to as dually-eligible beneficiaries or dual eligibles — receive their primary health insurance coverage through Medicare and some assistance from their state Medicaid program. (Medicare is a federal program, while Medicaid is jointly funded by states and the federal government.) In 2019, Medicare-Medicaid enrollees comprised 17 percent of the traditional Medicare population but accounted for 33 percent of traditional Medicare spending. They made up 14 percent of the total Medicaid population and accounted for 32 percent of all Medicaid spending.

Virtually all Medicare-Medicaid enrollees have low incomes and very modest savings, but they are otherwise a diverse population. For example, they include some seniors who are in relatively good health, as well as adults of all ages with serious medical, functional and cognitive impairments, including lifelong intellectual and developmental disabilities.

• In 2020, 73% of the 12.5 million people who were enrolled in both Medicare and Medicaid were eligible for full Medicaid benefits, such as long-term services and supports.
• The vast majority (87%) had an income of less than $20,000, and nearly half (49%) were people of color.
• Almost 40% were under age 65 and eligible for Medicare due to disability, and 44% were in fair or poor health.
• Medicare spending per Medicare-Medicaid enrollee in traditional Medicare was substantially higher than per capita spending for other Medicare beneficiaries ($23,235 for full-benefit enrollees and $18,427 for partial-benefit enrollees versus $9,448 for all other Medicare beneficiaries without Medicaid coverage).
• Medicaid spending per Medicare-Medicaid enrollee was more than 7-times greater for full-benefit enrollees than for partial-benefit enrollees ($19,811 versus $2,683), Average spending for all other Medicaid enrollees (those without Medicare) was $5,387.

The two new analyses are:

• A Profile of Medicare-Medicaid Enrollees (Dual Eligibles)
• Enrollment and Spending Patterns Among Medicare-Medicaid Enrollees (Dual Eligibles)

The two new analyses are:

KFF also has a special collection in our State Health Facts database featuring the latest data on the number of Medicare-Medicaid enrollees in each state as well as Medicare and Medicaid spending on these enrollees.

Medicare and Medicaid are the two largest public health insurance programs in the United States. Medicare is the primary source of health insurance coverage for people ages 65 and older and covers people under 65 with long-term disabilities who qualify for Medicare through the Social Security Disability Insurance program. Medicare is a federal program financed primarily by general revenues, payroll tax contributions, and premiums. Medicaid is the nation’s largest public health insurance program for low-income Americans and the primary payer for long-term services and supports. The federal government sets core Medicaid requirements, but states have some flexibility with respect to the people they cover and the benefits they provide. Medicaid is jointly funded by states and the federal government. The federal government matches state spending for eligible beneficiaries and qualified services without a limit. The federal share of spending for most Medicaid enrollees is determined by a formula that provides a match of at least 50% and provides a higher match for states with lower per capita income relative to the national average.

Medicare-Medicaid enrollees, also referred to as dually eligible beneficiaries or “dual eligibles”, are enrolled in both programs. They receive their primary health insurance coverage through Medicare and receive some assistance from their state Medicaid program. Of the 12.5 million beneficiaries enrolled in both Medicare and Medicaid in 2020, most (73%) were “full-benefit” Medicare-Medicaid enrollees who are eligible for the full range of Medicaid benefits that are not otherwise covered by Medicare, such as long-term services and supports. States are required to provide certain services such as nursing facility care and transportation to medical appointments, and may choose to provide additional services such as home and community-based services and dental care. “Partial-benefit” Medicare-Medicaid enrollees are not eligible for full Medicaid benefits but are eligible for assistance with Medicare premiums and, in many cases, cost sharing through the Medicare Savings Programs (see Box 1).

This brief examines national and state-level data on enrollment and spending for Medicare-Medicaid enrollees using the 2019 and 2020 Medicare Beneficiary Summary Files and the 2019 Transformed Medicaid Statistical Information System (T-MSIS) (see Methods box for details). Spending data for Medicare includes beneficiaries in traditional Medicare only, since spending data for beneficiaries enrolled in Medicare Advantage plans are unavailable. State-level data on Medicare-Medicaid enrollment and spending are available through KFF’s State Health Facts.

Key findings include:

• In 2020, 12.5 million people were enrolled in both Medicare and Medicaid, 73% of whom were eligible for full Medicaid benefits, such as long-term services and supports.
• In 2019, Medicare-Medicaid enrollees comprised 17% of the traditional Medicare population and 14% of the total Medicaid population but accounted for a higher share of spending in both programs: 33% of traditional Medicare spending and 32% of Medicaid spending.
• Medicare spending per Medicare-Medicaid enrollee in traditional Medicare was higher for full-benefit enrollees than partial-benefit enrollees, and both amounts were substantially higher than per capita spending for other Medicare beneficiaries ($23,235 for full-benefit enrollees versus $18,427 for partial-benefit enrollees versus $9,448 for all other Medicare beneficiaries without Medicaid coverage).
• Medicaid spending per Medicare-Medicaid enrollee was more than 7-times greater for full-benefit enrollees than for partial-benefit enrollees ($19,811 versus $2,683), because Medicaid only paid for Medicare premiums and in many cases, cost sharing for partial-benefit Medicare-Medicaid enrollees. Average spending for all other Medicaid enrollees (those without Medicare) was $5,387. Most Medicaid enrollees without Medicare are children and adults under age 65, who do not qualify on the basis of disability and are less likely to use costly long-term services and supports covered by Medicaid.

How many people were enrolled in both Medicare and Medicaid?

In 2020, 12.5 million people were enrolled in both Medicare and Medicaid (Figure 1). Among Medicare-Medicaid enrollees, 9.1 million (73%) were full-benefit enrollees and 3.4 million (27%) were partial-benefit enrollees.

Medicare-Medicaid enrollees comprised 20% of the total Medicare population (including beneficiaries in both traditional Medicare and Medicare Advantage) and 14% of the total Medicaid population, but the shares varied widely across states. In 2019, Medicare-Medicaid enrollees comprised over 25% of all Medicare beneficiaries in Connecticut, the District of Columbia, Louisiana, Maine, Mississippi, and New York, but only 10% in Utah. Medicare-Medicaid enrollees accounted for more than 20% of Medicaid enrollees in Alabama, Maine, and Mississippi, but less than 10% in Alaska, and Minnesota.

Federal law defines minimum eligibility criteria for Medicaid but states have flexibility to adopt more permissive Medicaid eligibility criteria than federal standards. Variation across states in the share of the Medicare population with both Medicare and Medicaid coverage depends mainly on the income and asset distribution of the Medicare population and Medicaid eligibility criteria for adults who have disabilities or are age 65 or older. The percentage of Medicare beneficiaries who are Medicare-Medicaid enrollees is higher in states where more people meet financial eligibility criteria—either because more people have limited financial resources or because the state has extended Medicaid eligibility to a broader segment of the Medicare population. Variation across states in the share of the Medicaid population with both Medicare and Medicaid depends primarily on how state eligibility criteria for adults who have disability or are age 65 or older compare with the eligibility criteria for children, pregnant women, and other adults.

How much did Medicare and Medicaid spend on Medicare-Medicaid enrollees?

In 2019, Medicare spent $152 billion on Medicare-Medicaid enrollees in traditional Medicare, while Medicaid spending on Medicare-Medicaid enrollees was $190 billion. Medicare-Medicaid enrollees accounted for a larger share of spending in each program than their respective shares of Medicare and Medicaid enrollment (Figure 3). Medicare-Medicaid enrollees comprised 17% of the traditional Medicare population but accounted for 33% of traditional Medicare spending. (These estimates include spending for the 6.8 million Medicare-Medicaid enrollees in traditional Medicare only, excluding the 5.5 million Medicare-Medicaid enrollees in Medicare Advantage, because Medicare spending data are not available for beneficiaries enrolled in Medicare Advantage plans). Medicare-Medicaid enrollees comprised 14% of Medicaid enrollment but 32% of federal and state Medicaid spending.

How much did Medicare and Medicaid spend per Medicare-Medicaid enrollee?

In 2019, Medicare spent $23,235 per full-benefit Medicare-Medicaid enrollee in traditional Medicare, on average, compared with $18,427 per partial-benefit Medicare-Medicaid enrollee in traditional Medicare and $9,448 per traditional Medicare beneficiary not enrolled in Medicaid. Higher average per capita Medicare spending among full-benefit Medicare-Medicaid enrollees likely reflects their poorer health status and greater need for medical care: in 2020, full-benefit Medicare-Medicaid enrollees were more likely to be in fair or poor health and have mental health conditions or Alzheimer’s disease and other types of dementia relative to partial-benefit Medicare-Medicaid enrollees or Medicare beneficiaries without Medicaid. Those conditions have been associated with higher spending, including higher hospitalizations and emergency department visits. Full-benefit Medicare-Medicaid enrollees were also more likely to have limitations in activities of daily living (ADLs) than partial-benefit Medicare-Medicaid enrollees or Medicare beneficiaries without Medicaid. Higher Medicare spending among full-benefit Medicare-Medicaid enrollees also may reflect their ability to access health care services without substantial financial barriers associated with cost sharing, since most full-benefit Medicare-Medicaid enrollees receive Medicaid coverage of Medicare cost sharing. In addition, this group has access to certain Medicaid benefits, such as non-emergency medical transportation and case management, which could ease access barriers and increase use of Medicare-covered services.

In 2019, Medicaid spent $19,811 per full-benefit Medicare-Medicaid enrollee compared with $2,683 per partial-benefit Medicare-Medicaid enrollee, and $5,387 per Medicaid enrollee without Medicare. Medicaid per capita spending for partial-benefit Medicare-Medicaid enrollees was considerably lower than for full-benefit enrollees because Medicaid only pays for premiums and, in many cases, cost sharing for partial-benefit enrollees. Higher Medicaid per capita spending for full-benefit Medicare-Medicaid enrollees reflects coverage of Medicaid benefits in addition to spending on Medicare premiums and, in many cases, cost sharing. Medicaid per capita spending for full-benefit Medicare-Medicaid enrollees was several times larger than for Medicaid enrollees without Medicare, both because of higher health care needs among full-benefit Medicare-Medicaid enrollees, which leads to higher per capita spending, and because most Medicaid enrollees (without Medicare) are children and adults under age 65 who do not qualify on the basis of a disability and tend to have lower per capita spending.

Medicare and Medicaid spending per full-benefit Medicare-Medicaid enrollee varied across states. In 2019, Medicare spending per full-benefit Medicare-Medicaid enrollee in traditional Medicare ranged from $16,032 in New Mexico to $29,360 in Florida. Medicaid spending per full-benefit Medicare-Medicaid enrollee ranged from $10,826 in South Carolina to $43,933 in North Dakota. A myriad of factors could be contributing to the variation in state spending, including but not limited to, variation across states in Medicare-Medicaid enrollees’ health and long-term care needs, variation in state Medicaid programs’ eligibility criteria and covered benefits, differences in payment rates, and geographic differences in the use of health care.

Conclusion

Medicare-Medicaid enrollees account for a higher share of spending relative to their share of enrollment in both Medicare and Medicaid, likely because Medicare-Medicaid enrollees tend to have greater health and functional needs than people who are enrolled in only Medicare or only Medicaid. Several initiatives have been launched that aim to improve health care and reduce spending for Medicare-Medicaid enrollees by integrating the financing and delivery of care across the Medicare and Medicaid programs. Currently, there is mixed evidence on the effect of these initiatives on health outcomes, access to care, and spending. Given the high costs and significant needs of Medicare-Medicaid enrollees as a group, it is likely that policymakers will continue to explore new policy options for improving the coordination and delivery of care between the Medicare and Medicaid programs.

The 12.5 million people who are jointly enrolled in Medicare and Medicaid, Medicare-Medicaid enrollees (also referred to as dually-eligible beneficiaries or dual eligibles), receive their primary health insurance coverage through Medicare and some assistance from their state Medicaid program. Medicare is a federal program financed primarily by general revenues, payroll tax contributions, and premiums. Medicaid is the nation’s largest public health insurance program for low-income Americans and the primary payer for long-term services and supports. People enrolled in both Medicare and Medicaid comprise 17% of Medicare beneficiaries in traditional Medicare and 14% of Medicaid enrollees, but much higher shares of spending (33% of traditional Medicare spending and 32% of Medicaid spending).

While virtually all Medicare-Medicaid enrollees have low incomes and very modest savings, they are otherwise a heterogenous group in age, physical and mental health. Medicare-Medicaid enrollees include people ages 65 and over who are in relatively good health but have limited financial resources and people who at one time, may have had more financial resources, but spent their income and wealth on health or long-term care costs. They include people with lifelong intellectual and developmental disabilities who have always faced employment challenges and people under the age of 65 with robust work histories who left the labor force on account of significant physical or mental impairments.

Among the 12.5 million Medicare-Medicaid enrollees in 2020, most (73%) were “full-benefit” Medicare-Medicaid enrollees who were eligible for the full range of Medicaid benefits not otherwise covered by Medicare, such as long-term services and supports. Medicaid is jointly funded by states and the federal government. The federal government matches state spending for eligible beneficiaries and qualified services without a limit. The federal share of spending for most Medicaid enrollees is determined by a formula that provides a match of at least 50% and provides a higher match for states with lower per capita income relative to the national average. Most—but not all—full-benefit Medicare-Medicaid enrollees are also eligible for Medicare premium and cost-sharing assistance covered under the Medicare Savings Programs, which are administered by states. “Partial-benefit” Medicare-Medicaid enrollees are not eligible for full Medicaid benefits, but are eligible for assistance with Medicare premiums and, in many cases, cost sharing through the Medicare Savings Programs (see Box 1).

This brief examines the demographic, socioeconomic, and health characteristics of Medicare-Medicaid enrollees using the 2020 Medicare Current Beneficiary Survey (see Methods for details). It highlights the diversity within the Medicare-Medicaid population and how Medicare-Medicaid enrollees differ from all other Medicare beneficiaries.

Key takeaways

• Among all Medicare-Medicaid enrollees, 87% had an income of less than $20,000, compared to 20% of all Medicare beneficiaries without Medicaid coverage.
• Almost 40% of Medicare-Medicaid enrollees were under age 65 and eligible for Medicare because they had received 24 months of Social Security Disability Insurance payments, compared to 8% of Medicare beneficiaries without Medicaid.
• Nearly half of all Medicare-Medicaid enrollees (49%) were people of color compared to less than 20% of Medicare beneficiaries without Medicaid coverage.
• More than four in 10 Medicare-Medicaid enrollees (44%) were in fair or poor health compared to 17% of Medicare beneficiaries without Medicaid. At the same time, 21% of full-benefit and 27% of partial-benefit Medicare-Medicaid enrollees reported excellent or very good health.
• Among Medicare-Medicaid enrollees, 48% had at least one limitation in activities of daily living (ADLs) compared to 23% of Medicare beneficiaries without Medicaid coverage. A larger share of full-benefit enrollees (40%) than partial-benefit enrollees (23%) had two or more limitations in ADLs.

What were the demographic and socioeconomic characteristics of Medicare-Medicaid enrollees?

Almost nine in ten Medicare-Medicaid enrollees (87%) lived on an annual income below $20,000 compared to one in five Medicare beneficiaries without Medicaid coverage (20%) (Figure 1, Income tab). While the vast majority of Medicare-Medicaid enrollees had relatively low incomes, partial-benefit Medicare-Medicaid enrollees had somewhat higher incomes compared to full-benefit Medicare-Medicaid enrollees, specifically a larger share of full-benefit than partial-benefit Medicare-Medicaid enrollees lived on incomes below $10,000 per year in 2020 (45% vs 27%).

Medicare-Medicaid enrollees with higher incomes may become eligible for Medicaid if they “spend down” their income due to large medical or long-term care expenses. Conversely, a small share of Medicare beneficiaries without Medicaid (3%) had an income of less than $10,000. These beneficiaries may not be enrolled in Medicaid because their assets exceeded the limit, they were unaware of the programs, or because they were unable to enroll on account of administrative burdens.

More than one in ten full-benefit Medicare-Medicaid enrollees (13%) lived in a long-term care nursing home or other institutional facility, compared to 1% of all Medicare beneficiaries without Medicaid coverage (Figure 1, Residence tab). More full-benefit Medicare-Medicaid enrollees living in institutional settings relative to all other Medicare beneficiaries likely reflects Medicaid eligibility provisions and the high costs of nursing facility care. The average cost of a private room in a nursing facility was over $108,000 in 2021. After spending their income and savings to pay for those costs, Medicare beneficiaries without Medicaid may become eligible for Medicaid coverage. In addition, Medicare beneficiaries who use long-term services and supports who meet other eligibility criteria  may qualify for Medicaid, if for example, they can demonstrate the need for an institutional level of care and meet other income and asset criteria.

Almost four in ten (37%) Medicare-Medicaid enrollees were under age 65 and qualified for Medicare on account of a long-term disability compared to fewer than one in ten Medicare beneficiaries without Medicaid (8%) (Figure 1, Age tab). People under age 65 are entitled to Medicare when they have received Social Security Disability Insurance benefits for 24 months. Medicare beneficiaries younger than age 65 differ from beneficiaries age 65 and older in terms of their medical conditions, service utilization, and income.

More than half (51%) of Medicare-Medicaid enrollees were people of color compared with 20% of Medicare beneficiaries without Medicaid. Overall, Medicare-Medicaid enrollees were more racially and ethnically diverse than Medicare beneficiaries without Medicaid: about half (49%) were White, 22% were Black, 20% were Hispanic, and 9% belong to other racial/ethnic groups (Figure 1, Race/Ethnicity tab). In contrast, 81% of Medicare beneficiaries without Medicaid were White and 19% were from communities of color. Full-benefit Medicare-Medicaid enrollees were less likely to be White and more likely to be Hispanic than partial-benefit Medicare-Medicaid enrollees.

What were the health characteristics of Medicare-Medicaid enrollees?

More than four in ten Medicare-Medicaid enrollees (44%) were in fair or poor health compared with 17% of Medicare beneficiaries without Medicaid coverage (Figure 2, Health Status tab). Conversely, nearly one-quarter (23%) reported being in excellent or very good health. Among Medicare-Medicaid enrollees there were differences in their reported health status: 46% of full-benefit Medicare-Medicaid enrollees and 40% of partial-benefit Medicare-Medicaid enrollees reported fair or poor health.

About one-quarter (26%) of Medicare-Medicaid enrollees had five or more chronic conditions, compared to 15% of Medicare beneficiaries without Medicaid coverage (Figure 2, Number of Chronic Conditions tab). Among Medicare-Medicaid enrollees, similar shares of full- and partial-benefit enrollees reported having five or more chronic conditions (26% for both groups), three or four chronic conditions (37% and 38%, respectively), one or two chronic conditions (30% for both groups), and no chronic conditions (7% and 6%, respectively).

Full-benefit Medicare-Medicaid enrollees were over twice as likely to have had a mental health condition than Medicare beneficiaries without Medicaid coverage. Half (50%) of full-benefit Medicare-Medicaid enrollees reported having a mental health condition compared with less than 25% of Medicare beneficiaries without Medicaid. The share of partial-benefit Medicare-Medicaid enrollees with a mental health condition (40%) was between the share of Medicare enrollees without Medicaid coverage and full-benefit enrollees (Figure 3, Mental Health Condition tab).

The share of beneficiaries with Alzheimer’s disease or other dementia was substantially higher among full-benefit Medicare-Medicaid enrollees than among partial-benefit Medicare-Medicaid enrollees or Medicare beneficiaries without Medicaid. Specifically, 11% of full-benefit Medicare-Medicaid enrollees had Alzheimer’s or other dementia compared to 3% of Medicare beneficiaries without Medicaid and 5% of partial-benefit Medicare-Medicaid enrollees.

About one in six full-benefit Medicare-Medicaid enrollees had an intellectual or developmental disability compared to just 5% of Medicare beneficiaries without Medicaid coverage. Among full-benefit Medicare-Medicaid enrollees, 16% had an intellectual or developmental disability compared to only 1% of Medicare beneficiaries without Medicaid coverage and 5% of partial-benefit Medicare-Medicaid enrollees (Figure 3, Intellectual/Developmental Disability tab).

Medicare-Medicaid enrollees were more likely than Medicare beneficiaries without Medicaid to report having a limitation in activities of daily living (ADL), which include eating, bathing, toileting, dressing, and functional mobility. Specifically, 48% of Medicare-Medicaid enrollees had at least one ADL limitation, compared to 23% of all Medicare beneficiaries without Medicaid coverage.

Among full-benefit Medicare-Medicaid enrollees, 40% reported having limitations in 2 or more ADLs, 13% had 1 limitation in an ADL, and just under half (48%) had no limitations in ADLs (Figure 3, Number of ADLs tab). In comparison, a smaller share (23%) of partial-benefit Medicare-Medicaid enrollees reported limitations in 2 or more ADLs, while somewhat higher shares had 1 limitation in an ADL (17%) or no limitations in ADLs (60%).

Conclusion

Overall, Medicare-Medicaid enrollees had lower incomes, were more racially and ethnically diverse, and were more likely to be in poorer health with greater health needs than Medicare beneficiaries without Medicaid coverage. Medicare-Medicaid enrollees are themselves a population with diverse needs and circumstances; while many live with serious physical and mental health challenges, nearly one in four Medicare-Medicaid enrollees reported being in excellent or very good health and more than half had no functional impairment. There were also differences between full- and partial-benefit enrollees. Full-benefit enrollees were more likely to live in an institutional setting, such as a long-term care nursing home, have had an intellectual or developmental disability, and more limitations in activities of daily living. Even within each of these groups there was variation in terms of Medicare-Medicaid enrollees’ demographic, socioeconomic, and health characteristics.

The heterogeneity of the Medicare-Medicaid population highlights the challenges policymakers face when developing targeted strategies to improve the coordination and management of care for these 12.5 million beneficiaries, while balancing the potential for more simplicity and efficiency against flexibility necessary to meet the diverse needs of this group.

In recent months, there has been increased focus on immigration trends and the evolving landscape of immigration policies, amid increasing immigration activity at the U.S.-Mexico border. In 2021, there were 20.8 million noncitizens and 23.9 million naturalized citizens residing in the U.S., who accounted for about 6% and 7% of the total population, respectively. Noncitizens include lawfully present and undocumented immigrants. Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens, including the one in four children who have an immigrant parent. Over the last two years, there has been a surge in immigration activity at the border, with over 2 million encounters at the U.S.-Mexico border in 2022. Against this backdrop, there have been ongoing changes to several key immigration policies. reflecting actions by the Biden Administration and court rulings.

This issue brief provides the latest update on some key evolving immigration policies, including Title 42 as it applies to border enforcement, the Deferred Action for Childhood Arrivals (DACA) program, and the public charge rule and discusses the implications of these policies for the health and well-being of immigrants.

Title 42

Title 42 restrictions will lift when the COVID-19 public health emergency (PHE) declaration ends on May 11, 2023.

Title 42 of the Public Health Services Act is a public health authority that authorizes the Director of the Centers for Disease Control and Prevention (CDC) to suspend entry of individuals into the U.S. to protect public health. This authority was implemented by the Trump Administration in March 2020 in response to the COVID-19 pandemic to allow for quick expulsion of migrants, including asylum seekers, seeking entry into the U.S. at the land borders. After taking office, the Biden Administration continued to enforce Title 42, with new exceptions provided to unaccompanied minors, but announced plans to end the suspension of entry in 2022. Due to court challenges, the policy remained in place pending the Supreme Court hearing arguments on whether a coalition of states, including Texas, could challenge a lower court ruling that ordered the policy be lifted. However, on February 16, 2023, the Supreme Court canceled the hearing for these arguments, following filing of a brief from the Biden Administration arguing that the case would become moot since the Biden Administration announced an end to the COVID-19 public health emergency (PHE) on May 11, 2023, which will consequently end the Title 42 border restrictions as well.

In 2022, over 1 million, or almost half (45%), of all migrant encounters at the border were under Title 42 authority. A vast majority (89%) of the Title 42 expulsions were of single adults. Research shows Title 42 expulsions have negatively impacted the health and well-being of migrant families. Physicians suggest that being in close proximity with other individuals while being temporarily detained or transported back to Mexico, lack of medical screenings, and lack of provision of necessary medication can all have adverse impacts on physical and mental health.

It is expected that immigration activity at the border will increase if Title 42 is lifted, and the Biden Administration has outlined new actions it will take to enhance border enforcement. If Title 42 is lifted, it will be increasingly important to address health and health care needs in border areas, given the disparities and challenges in these areas, particularly in the Texas border region (Figure 1). The Biden Administration has announced plans to increase security and enforcement at the border to reduce unlawful crossings, expand “legal pathways for orderly migration”, invest additional resources in the border region, and partner with Mexico to implement the aforementioned plans.

Deferred Action for Childhood Arrivals (DACA) Program

Under current court orders, the government is not processing first-time DACA applications, but existing DACA approvals remain in place and can be renewed.

The DACA program was originally established under a Presidential Executive Order in June 2012 to protect certain undocumented immigrants who were brought to the U.S. as children from removal proceedings and receive authorization to work for renewable two-year periods. To be eligible, individuals must have arrived in the U.S. prior to turning 16 and before June 15, 2007; be under the age of 31 as of June 15, 2012; be currently enrolled in school, have completed high school or its equivalent or be a veteran; and have no lawful status as of June 15, 2012. The program has enabled over 900,000 immigrants to stay in the U.S., go to school, and contribute to the economy through gainful employment.

As of September 30, 2022, there were over 589,000 DACA recipients in the U.S. A majority (58%) of active DACA recipients live in California, Texas, Illinois, New York, and Florida, 54% are female, and 65% are between the ages of 21 and 30 years.

While DACA protects an individual from removal action for a certain period of time, it does not provide lawful status or a pathway to U.S. citizenship, and people with DACA status remain ineligible for federally-funded health coverage. Individuals with DACA status can be authorized to work, and studies have found that DACA eligibility helps improve physical and mental health, particularly among individuals with low incomes, and can improve the wellbeing of children of DACA recipients. However, individuals with DACA have limited options for health insurance coverage if they do not have access to employer-sponsored insurance since they remain ineligible for many federal programs, including health coverage through Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act (ACA) health insurance Marketplaces.

The Biden Administration published a final rule in 2022 that would codify DACA largely consistent with its existing eligibility requirements and scope, but it’s implementation is limited subject to court orders. Promulgation of this rule followed a rescission of the program by the Trump Administration in 2017 that was ruled unlawful by the Supreme Court in 2020. While the Biden Administration’s final rule became effective on October 31, 2022, its implementation is limited subject to ongoing litigation. A federal appeals court ruling in early October 2022 found the original 2012 DACA policy to be unlawful and remanded the case back to the district court for further proceedings per the new regulations. Subject to current court orders, as of October 31, 2022, current DACA approvals and work authorizations remain in effect, and the Department of Homeland Security will continue to process DACA renewal requests and related requests for employment authorization. It is also accepting initial DACA and employment authorization requests, however, it cannot process initial requests under the current court orders, so these requests remain on hold.

Even if processing of first-time DACA applications were reinstated, the number of young adults who may benefit from DACA is dwindling. Given the requirements to have entered the U.S. prior to June 15, 2007, and to be under the age of 31 as of June 15,2012, the number of people who could be eligible for DACA is decreasing over time. The American Dream and Promise (DREAM) Act of 2021 would provide a pathway to lawful permanent resident status and eventually citizenship for undocumented immigrants who were brought to the U.S. as children and who meet certain requirements. Different versions of this Act have been proposed in the U.S. Congress since 2001, but have never been passed, and there does not appear to be a current pathway to passage for such legislation.

If the district court reviewing the current case finds the DACA program to be unlawful and no additional legislative or administrative action is taken, individuals will lose their deferred status. Loss of DACA status would result in individuals losing work authorization and potentially being subject to deportation. Employers would likely terminate individuals as they lose work authorization, leading to job losses along with loss of employer-based health coverage. Without access to coverage through an employer, many individuals would likely become uninsured since they are not eligible to enroll in Medicaid or CHIP or to purchase coverage through the Marketplaces. Employment and coverage losses would lead to increased financial pressure and reduced access to care for individuals and their families, who may include citizen children.

Public Charge Rule

As of December 23,2022, the Biden Administration’s new public charge regulations went into effect, but continued outreach and education efforts will be key for reducing fears about enrolling in health coverage and other assistance programs among immigrant families.

Under longstanding immigration policy, federal officials can deny entry to the U.S. or adjustment to LPR status (i.e., a “green card”) to someone they determine to be a public charge. In 2021, the Biden Administration stopped applying public charge regulations implemented by the Trump Administration in 2019 that had newly considered the use of noncash assistance programs, including Medicaid, in public charge determinations. Instead, it returned to the use of 1999 field guidance, which does not consider the use of noncash benefits including Medicaid coverage, except for long-term institutionalization, in making public charge determinations., In 2022, it issued new regulations that largely codified this field guidance. A primary stated aim of the 2022 public charge rule is to address chilling effects of the 2019 rule that led many immigrant families, including citizen children in these families, to not seek assistance including health coverage and care, for which they were eligible.

The final public charge rule was published on September 9, 2022 and went into effect on December 23, 2022, but families may continue to avoid participating in assistance programs due to fears of potential negative consequences on their or a family member’s immigration status. A 2021 KFF survey of Hispanic adults found that 1 in 4 potentially undocumented Hispanic adults and over 1 in 10 lawful permanent resident Hispanic adults reported that they or a family member did not participate in a government assistance program in the past three years due to immigration-related fears (Figure 3). Even with the new rule now in effect, overcoming these fears will likely require sustained outreach efforts from trusted community-based messengers. Addressing these fears will be key for helping to narrow the large gaps in health coverage for immigrants and citizen children in immigrant families.

Immigrants are a diverse and growing population that makes important contributions to U.S. culture and economy. As immigration policies continue to evolve due to legislative, administrative, and judicial action, it is important to understand how these changes impact immigrants’ access to health care and the overall health and well-being of immigrant families.

The share of people who say they have had long COVID has declined since the summer, according to a new KFF analysis of self-reported data from the Centers for Disease Control and Prevention.

Among people who have ever had COVID, the share who say they currently or have ever had long COVID declined from 35% in June 2022 to 28% in January 2023, finds the analysis of data from the CDC’s Household Pulse Survey.

The decline was driven by a reduction in the share who currently reported active symptoms, which fell from about 1 in 5 people (19%) to about 1 in 10 (11%) during the same period.

Long COVID remains a serious concern that affects millions of Americans. As of January 16, 15 percent of all adults in the U.S. report having had long COVID symptoms at some point, including 6 percent who had current symptoms.

The findings come at a time when only 15 percent of the U.S. population meets the CDC’s definition of being up to date on their COVID vaccines. (The evidence — from other research — is mixed as to whether vaccines reduce the likelihood of getting long COVID, or if they reduce the severity of long COVID among people who already have it.)

The new analysis also finds that:

• Among those who have ever had long COVID, over half are no longer reporting symptoms.
• Among people with long COVID, 79 percent report having limitations to their day-to-day activities, and 27 percent characterize the limitations as significant.

Roughly two-thirds (65%) of people who were disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP) in a recent year became uninsured for all or part of the 12 months that followed, a new KFF analysis finds.

The analysis of enrollment data from the 2016-2019 Medical Expenditure Panel Survey (MEPS) suggests that many of the millions of people across the U.S. who are expected to lose Medicaid following the end of the pandemic-era continuous enrollment provision could end up without health coverage for months or more. By 12 months out, however, most people who were disenrolled will have obtained coverage again, either through re-enrolling in Medicaid or transitioning to private insurance.

Beginning April 1, 2023, state Medicaid programs will resume disenrollments for the first time since March 2020. Some people will lose coverage during this “unwinding” because they are no longer eligible for Medicaid and will become uninsured if they do not transition to other coverage, such as the Affordable Care Act (ACA) marketplaces or employer-sponsored insurance. Others will likely lose coverage for administrative reasons — despite still being eligible for Medicaid.

The new study also finds that 41% of people who were disenrolled from Medicaid or CHIP, including some who initially transitioned to other coverage, eventually re-enrolled in the program before a year had passed — a phenomenon of cycling in and out of Medicaid coverage known as “churn”.

In a previous analysis KFF estimated that between 5 and 14 million people will lose Medicaid coverage when states “unwind” the continuous enrollment provision this year.

Although the new findings highlight that many people do not transition to and retain other coverage after they disenroll from Medicaid/CHIP, states’ policies for the unwinding will have a major impact on how successful people will be in moving to other coverage.

State Medicaid agencies can take several steps to reduce coverage disruptions and churn, including improving state eligibility systems, streamlining renewal procedures, communicating with enrollees about the need to complete a renewal, and facilitating transitions to the ACA marketplace or separate Children’s Health Insurance Program (CHIP) coverage for people found ineligible for Medicaid. The federal government has issued guidance aimed at reducing coverage disruptions for Medicaid enrollees and has imposed new reporting requirements to monitor states’ unwinding processes.

At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a temporary requirement that Medicaid programs keep people continuously enrolled and, in exchange, states received enhanced federal funding. Under the continuous enrollment provision, Medicaid enrollment has grown substantially compared to before the pandemic and the national uninsured rate has declined. Provisions in the Consolidated Appropriations Act (CAA), signed into law in December 2022, end the continuous enrollment provision on March 31, 2023, and phase down the enhanced federal Medicaid matching funds through December 2023. When the continuous enrollment provision ends, however, millions of people could lose Medicaid, potentially reversing recent gains in health insurance coverage.

A key question is whether people losing Medicaid will be able to transition to and retain other forms of coverage, including Affordable Care Act (ACA) marketplace plans with premium assistance or employer-sponsored health benefits.

This brief uses pre-pandemic data from the 2016-2019 Medical Expenditure Panel Survey (MEPS) to examine the extent to which people enroll in and retain other coverage during the 12 months following disenrollment from Medicaid/CHIP. See the “Methods” section at the end of this brief for more details. Key findings include:

• In the year following a disenrollment from Medicaid/CHIP, roughly two-thirds (65%) of people had a period of uninsurance.
• Roughly four in ten (41%) people who disenrolled from Medicaid/CHIP eventually re-enrolled in Medicaid/CHIP within a year (or “churn”).

Key Findings

In the year that followed a disenrollment from Medicaid/CHIP, roughly two-thirds (65%) of people had a period of uninsurance while just 35% were continuously enrolled in coverage (Figure 1). The 65% of Medicaid/CHIP enrollees who experienced uninsurance after disenrolling consists of people who were: uninsured for the full year (17%), uninsured for some of the year and had another source of coverage during the year (16%), and uninsured after disenrolling but eventually re-enrolled in Medicaid/CHIP (or “churned”) before the end of the year (33%). The 35% of Medicaid/CHIP enrollees who maintained coverage for the full year after disenrollment from Medicaid/CHIP consist of people who: were enrolled in another source of coverage for the full year (26%) and had another source of coverage for some of the year but also re-enrolled in Medicaid/CHIP before the year ended (9%). Notably, most¹  of the people who were covered for the full year after disenrollment had a period of overlapping coverage before losing Medicaid/CHIP during which time they had both Medicaid/CHIP and private health insurance.

Roughly four in ten (41%) people who disenrolled from Medicaid/CHIP would eventually go on to re-enroll in Medicaid/CHIP within a year (Figure 2). That group consists of people who re-enrolled in Medicaid/CHIP after a period of uninsurance (33%) and who re-enrolled after having other coverage (9%). Among all enrollees who churned, 79% were uninsured before they re-enrolled in Medicaid/CHIP. Churn occurs for several reasons. Enrollees may experience short-term changes in income that make them temporarily ineligible. Churn may also happen when people who are still eligible for Medicaid/CHIP lose coverage for administrative reasons, such as difficulties completing annual renewals. Ultimately, churning on and off Medicaid/CHIP can limit access to care and lead to delays in getting needed care. Even for people who have other coverage before re-enrolling in Medicaid/CHIP, churning can cause disruptions in coverage when it requires people to change their health care providers or to navigate through different benefit packages.

Implications

These findings highlight that many people do not transition to and retain other coverage after they disenroll from Medicaid/CHIP. Overall, 65% of the people had a gap in coverage during the year following disenrollment from Medicaid/CHIP and only 26% of people enrolled in and retained another source of coverage for the full year after losing Medicaid/CHIP coverage. Of people who disenroll from Medicaid/CHIP, 41% re-enrolled within the year. That number includes 33% who re-enrolled in Medicaid/CHIP after a period of uninsurance, suggesting that many people were still eligible when they lost Medicaid/CHIP coverage. Even among people who initially enrolled in other coverage, 34% did not retain it for the full year; these individuals eventually lost their other coverage (and become uninsured) or they re-enrolled in Medicaid/CHIP. Generally, people in our analysis who had overlapping coverage (i.e., Medicaid/CHIP and private coverage) prior to losing Medicaid/CHIP were less likely to become uninsured or churn compared to those who did not have overlapping coverage.

KFF estimates that between 5 and 14 million people will lose Medicaid coverage when states “unwind” the continuous enrollment provision this year. Beginning April 1, 2023, states can resume disenrollments for the first time since March 2020. Some of the people who will be disenrolled during the unwinding will be ineligible and will become uninsured if they do not transition to other coverage. Others will lose coverage for administrative reasons despite still being eligible. While the millions of people who lose coverage during the unwinding will face similar challenges as those included in this analysis, there are also important differences today. For one, Congress extended enhanced subsidies for the ACA marketplace, which were first included in the American Rescue Plan Act (ARPA) during the pandemic, making those plans more affordable through 2025. Additionally, because of the continuous enrollment provision, an increasing number of Medicaid enrollees today report also being enrolled in private insurance compared to before the pandemic, which should reduce coverage disruptions for these individuals when they disenroll from Medicaid. However, this only represents a subset of people who will be disenrolled during the unwinding process. Most individuals who will lose Medicaid during the unwinding because they are no longer eligible will still need to transition to (and retain) other health insurance to avoid a gap in coverage.

State Medicaid agencies and other stakeholders can take several steps to reduce coverage disruptions and churn during the unwinding period. Broadly, these actions could include improving state eligibility systems, streamlining renewal procedures, communicating with enrollees about the need to complete a renewal, and facilitating transitions to the ACA marketplace or separate CHIP coverage for people found ineligible for Medicaid. The federal government has issued guidance aimed at reducing coverage disruptions for Medicaid/CHIP enrollees and has imposed new reporting requirements to monitor states’ unwinding processes. Although our analysis provides a pre-pandemic baseline for peoples’ health insurance changes after losing Medicaid/CHIP coverage, state policies for the unwinding will have a major impact on whether people will be more successful in transitioning to other coverage after losing Medicaid compared to pre-pandemic trends.

1. Thirty-five percent of people disenrolled from Medicaid/CHIP had health coverage for the full year after disenrollment. Of these people, 71% had both Medicaid/CHIP and private health insurance before losing Medicaid/CHIP. Typically, these individuals only had 1 to 4 months of overlapping coverage before disenrolling from Medicaid/CHIP. Generally, people with multiple sources of coverage before disenrolling were more likely have coverage for the full year and were less likely to churn compared to people who did not have overlapping coverage. ↩︎

As 2023 kicks off, a number of issues are at play that could affect coverage and financing under Medicaid, the primary program providing comprehensive health and long-term care coverage to low-income Americans. The Consolidated Appropriations Act, passed in December 2022, ends the Medicaid continuous enrollment provision on March 31, 2023 with a phase-down in enhanced federal matching funds. The unwinding of this provision, as well as the trajectory of the pandemic and the economy, will have implications for Medicaid enrollees, providers, managed care plans, and the states that operate these programs. A divided Congress will make it difficult to pass federal legislation, and while the Administration is expected to continue to use existing authority to improve coverage, access, and health equity, limited action at the federal level will push even more policy focus to the states. The first glimpse of state policy priorities will be revealed in Governors’ state of the state addresses and proposed budgets. Within this context, this issue brief examines key issues to watch in Medicaid in 2023.

Medicaid Coverage and Financing

The Medicaid continuous enrollment provision in place during the pandemic has increased enrollment and reduced the uninsured rate, but will end in March 2023. Provisions in the Families First Coronavirus Response Act (FFCRA) required states to ensure continuous enrollment in Medicaid in exchange for enhanced federal matching funds during the Public Health Emergency (PHE). Largely due to these policies, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) grew to 91 million in September 2022, an increase of 27.9% from February 2020 (prior to the pandemic). KFF estimates that through federal fiscal year 2022, states received more than double the amount in federal fiscal relief relative to the costs of enrollment due to the continuous enrollment provision, with some variation across states. The Consolidated Appropriations Act ends the continuous enrollment provision on March 31, 2023, and phases down the enhanced federal Medicaid matching funds through December 2023. States can resume disenrollments beginning April 1 but must meet certain eligibility and reporting requirements to continue to be eligible for enhanced funding. An estimated 5 to 15 million people could lose Medicaid coverage during unwinding and how states manage the process could affect how many people are able to maintain coverage.

Debate about Medicaid expansion will shift back to the states. Democrats in Congress last year discussed a federal option to fill in the Medicaid coverage gap but ultimately did not pass it, and such an approach is now highly unlikely with divided control in Washington. The American Rescue Plan Act (ARPA) included a two-year fiscal incentive to encourage remaining “non-expansion” states to newly adopt the Affordable Care Act (ACA) Medicaid expansion. Over  2 million individuals living in the 11 states that have not adopted the ACA Medicaid expansion fall into the “coverage gap.” These individuals do not qualify for Medicaid (as their income exceeds Medicaid eligibility limits in their respective states) but have incomes below poverty, making them ineligible for premium subsidies in the ACA Marketplace. A KFF analysis shows that all non-expansion states would see a net fiscal benefit from the ARPA incentive for two years if they adopt the expansion. The ARPA federal incentive reignited discussion around Medicaid expansion in a few non-expansion states during the last state legislative session. Notably, every state that has adopted expansion since 2019 has done so not through legislative or executive processes, but as a result of a successful ballot initiative. Most recently, South Dakota became the 40th state to expand Medicaid after voters approved a ballot question in November 2022. Although expansion ballot initiatives have been successful in all seven states where they have gone to voters (Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah), most of the remaining non-expansion states do not have ballot initiative processes. North Carolina may be the state most likely to expand Medicaid next given how far efforts advanced last year, with active efforts in Kansas and Wyoming as well.

Some states and the Administration are expected to continue to implement incremental policies to expand coverage. ARPA included an option, made permanent in the Consolidated Appropriations Act, to allow states to extend postpartum coverage from 60 days to 12 months. Under current law, after the 60 days of postpartum coverage, many people who qualify for pregnancy-related Medicaid  lose that coverage because Medicaid eligibility levels for parents are much lower than for pregnant people in most states, and especially in non-expansion states. As of January 2023, more than two-thirds of the states have taken steps to extend postpartum coverage. The Consolidated Appropriations Act also included a requirement for all states to implement 12 months of continuous coverage for children. In addition, Oregon received waiver approval to provide continuous eligibility for children from birth to age 6 and 2 years of continuous eligibility for all enrollees ages 6 and up, including adults; other states are seeking similar waivers for multi-year continuous eligibility. KFF analysis shows that for children, continuous eligibility policies help to provide coverage stability. Finally, the Administration released a proposed regulation designed to make it easier for individuals to obtain and retain coverage.

New state and federal attention to Medicaid financing could emerge in 2023. Medicaid financing is shared by the federal government and the states. Consequently, economic factors that affect state revenues including inflation, supply chain issues, and declining labor force participation rates, along with phase-down of the enhanced FMAP tied to the end of the continuous enrollment provision will have fiscal implications for states. In our annual state survey, states noted that inflation and workforce shortages were driving higher labor costs and pressure from providers for rate increases. Many states use reimbursement methodologies for some provider types, such as nursing facilities, that may automatically adjust for inflation. In addition, at the federal level the House of Representatives is likely to focus on measures to reduce the federal deficit and, while unlikely to pass in the Senate, proposals to limit federal spending for Medicaid could be debated again in Congress.

What to Watch:

• What will happen to Medicaid enrollment during the unwinding of the continuous enrollment provision? How will changes vary across states? How many people losing Medicaid coverage will transition to other sources of insurance like the Affordable Care Act marketplaces, and what will happen to the number of uninsured?
• Will any additional states implement Medicaid expansion or other coverage expansions like 12-month postpartum coverage?
• How will administrative actions, including oversight of the unwinding of the continuous enrollment provision, waiver approvals, and new regulations contribute to changes in coverage?
• How will broader economic factors, like inflation, affect state financing of Medicaid and will Congress debate broader proposals to cap federal Medicaid spending?

Access and Health Equity

Capitated managed care remains the predominant delivery system for Medicaid in most states. More than three-quarters of states that contract with MCOs (35 of 41) reported that 75% or more of their Medicaid beneficiaries were enrolled in MCOs as of July 1, 2022. Several states have recently implemented Medicaid managed care programs. Beginning July 1, 2021, North Carolina implemented its first MCO program, enrolling more than 1.8 million Medicaid beneficiaries in MCOs as of December 2022. Missouri implemented the ACA Medicaid expansion in October 2021, enrolling all expansion adults in Medicaid MCOs, and Oklahoma expects to implement capitated, comprehensive Medicaid managed care in October 2023. State managed care contracts vary widely in the populations required to enroll, the services covered, and the quality and performance incentives and penalties employed. Five multi-state, for-profit “parent” firms – Centene, UnitedHealth Group, Anthem, Aetna/CVS, and Molina – each have Medicaid MCOs in 12 or more states and account for half of all Medicaid MCO enrollment. MCOs are expected to play a large role in helping enrollees maintain coverage during the unwinding of the continuous enrollment provision. The Administration is expected to release revised regulations about Medicaid managed care and assuring access in Medicaid in the Spring of 2023.

In response to the pandemic, all states took action to expand coverage and access to telehealth in Medicaid, particularly for behavioral health services. In particular, nearly all states added or expanded audio-only telehealth coverage. These policy changes contributed to high telehealth utilization by Medicaid enrollees during the pandemic, overall and especially for behavioral health services. The rapid expansion of Medicaid telehealth policies and utilization has prompted state and federal questions about the quality of services delivered via telehealth. Most states have implemented or are planning initiatives to assess telehealth quality, though many states report ongoing considerations and uncertainty over how to effectively evaluate quality. States also report actions to address other telehealth challenges, including access to technology and broadband, program integrity, outreach and education, and equity. Most states have or plan to adopt permanent Medicaid telehealth expansions that will remain in place after the pandemic, including expansions of allowable modalities, services, and providers. At the same time, some states are considering guardrails on such policies, particularly for audio-only telehealth.

Beyond telehealth, many states are taking steps to expand access to behavioral health services as the pandemic has heightened demand for these services. Nine in ten Americans believe the nation is in the midst of a mental health crisis. Behavioral health conditions (i.e., mental health and substance use disorders) are more prevalent in Medicaid enrollees compared to people with other coverage, with data from 2020 showing that approximately 39% of Medicaid enrollees were living with a mental health or substance use disorder. States have been expanding behavioral health benefits and access to care, including by adopting strategies to bolster the behavioral health workforce. These state efforts track with continued activity at the federal level: the Consolidated Appropriations Act and the 2022 Bipartisan Safer Communities Act included an array of provisions to expand access and funding for behavioral health, such as provisions to require guidance on expanding Medicaid-covered mental health services in schools, expand Certified Community Behavioral Health Clinics (CCBHC), fund new psychiatry residency positions, and eliminate administrative requirements to prescribe buprenorphine.

States and the Administration have identified advancing health equity as an important priority for the Medicaid program. The pandemic exacerbated longstanding racial and ethnic disparities in health and health care. Medicaid policies that could help address health equity include closing the “coverage gap” for adults in non-expansion states; increasing coverage among those eligible but not enrolled; and expanding benefits such as pregnancy and postpartum services, housing and housing-related supports, and community health worker services. High-quality, comprehensive data are essential for identifying and addressing health disparities and measuring progress over time and the majority of states are implementing strategies to improve race, ethnicity, and language (REL) data completeness. States are also using MCO financial quality incentives (e.g., performance bonuses, withholds) tied to health equity-related performance goals and other MCO contract requirements to advance health equity. Other reported state Medicaid initiatives to reduce racial health disparities include outreach to underserved populations, increasing cultural competency, and establishing departments and dedicated staff positions focused on promoting equity. In addition, states have received or are seeking Section 1115 waivers that aim to advance equity.

States and the Administration are implementing strategies to leverage Medicaid to address social determinants of health (SDOH) through managed care and Section 1115 waivers. The Biden Administration has encouraged states to propose waivers that expand coverage, reduce health disparities, and/or advance “whole-person care,” including by addressing health-related social needs (HRSN). Recent waivers approved in four states (AR, AZ, MA, and OR) include HRSN services to address food insecurity and/or housing instability for targeted populations. Additionally, following the approval of a California proposal to use “in lieu of” services (ILOS) to offer a menu of health-related services through managed care authority, the Centers for Medicare and Medicaid Services (CMS) recently released additional guidance on the use of in lieu of services and settings in Medicaid managed care to reduce health disparities and address unmet HRSN (such as housing instability and nutrition insecurity).

What to watch?

• How effective will state and administration efforts to leverage Medicaid be in addressing SDOH and reducing health disparities? How will states use authorities including Section 1115 and managed care to pursue these goals?
• What kinds of permanent telehealth expansions and/or guardrails will state Medicaid agencies adopt, and how will these policy changes be informed by data analyses, federal guidance, and cost concerns?
• Will the Administration release new guidance in 2023 to address access to care and what provisions will be included in the anticipated access and revised managed care regulations?
• Will Congress pass additional legislation and / or will states take additional actions to improve access to and funding for behavioral health services?

Enrollment and Access Among People Eligible for Medicaid through Age or Disability

The new proposed rule on eligibility and enrollment could increase enrollment among all Medicaid eligibility groups, but especially among seniors and people with disabilities. A proposed rule designed to make it easier for people to obtain and maintain coverage in Medicaid and CHIP includes provisions to simplify the enrollment and renewal processes for seniors and people with disabilities by applying many of the ACA’s simplified eligibility processes for children and other adult eligibility groups to these groups. There would also be simplified enrollment procedures for people who receive supplemental security income and people who are enrolled in Medicare but eligible for Medicaid coverage of Medicare premiums. KFF analysis finds that over one-third of Medicare-Medicaid enrollees lose Medicaid coverage within one year of their initial enrollment, which is one of the reasons for the proposed changes. CMS expects that the rule would increase Medicaid enrollment by nearly 3 million full-year equivalents, with seniors and people with disabilities accounting for over half of that total.

Staff and residents at long-term care facilities have been disproportionately affected by the pandemic. Over one-fifth of all deaths from COVID-19 were among residents and staff in long-term care facilities as of June 12, 2022. Although initial vaccination rates were high and the death rate among nursing facility residents and staff dropped, take-up of boosters and of the new bivalent booster has been much lower. Going into the 2022-2023 winter period, fewer than half of residents and one quarter of staff were up-to-date with their vaccinations, which may result in higher death rates moving forward. Compounding the challenges with COVID-19 illness is the ongoing workforce shortage for long-term care facilities. Whereas employment in most health care sectors has rebounded from the sharp drop in March 2020, employment in long-term care facilities remains well-below pre-pandemic levels.

The pandemic also highlighted workforce shortages and unmet need among people who use long-term services and supports (LTSS) delivered in home and community settings (HCBS). In a KFF survey of HCBS programs, nearly all states reported that workforce shortages were the number one impact of the COVID-19 pandemic on HCBS services and 44 states reported that at least one HCBS provider permanently closed. Virtually all states increased payment rates in response, but some of those increases are temporary rather than permanent. Many changes to HCBS programs relied on temporary funding through the ARPA or temporary authorities available during the PHE. Policymakers of both parties have called for additional and longer-term changes to HCBS including eliminating waiting lists for services, increasing opportunities for family members to be paid caregivers, enabling more people to live in their homes as they age, and permanently increasing wages for all HCBS providers.

There is bipartisan interest in improving the coordination for Medicare-Medicaid enrollees (also known as “dual eligibles”). People who are enrolled in both Medicare and Medicaid tend to have significant health and functional needs and higher health care spending than people with only Medicare or Medicaid. Policymakers have expressed interest in improving the coordination between Medicare and Medicaid with the goals of improved health outcomes and, possibly, reduced health care spending. Most recently, a bipartisan group of senators released a request for information, soliciting input from patients, providers, payors, and other stakeholders.

What to Watch:

• How will the final eligibility and enrollment rule increase enrollment for seniors and people with disabilities?
• Will nursing facility residents and staff be at increased risk of death as the virus evolves and immunity wanes among people who are vaccinated but not up to date? What efforts will emerge to improve rates of booster take-up?
• How will the end of ARPA funding and PHE authorities affect access to HCBS?
• Will bipartisan interest in improving the coordination between Medicare and Medicaid result in new legislation addressing Medicare-Medicare enrollees and their access to care?

Early in the COVID-19 pandemic, many outpatient visits and elective hospitalizations were delayed, avoided, or cancelled, leading to a sharp decline in health care utilization. However, there have been expectations that there will be pent-up demand for this missed care.

Using a variety of data sources, this chart collection examines the latest available data on how health services utilization has changed over the course of the pandemic. We find that, as of mid-to-late 2022, utilization of healthcare is generally rebounding, but some of that use is likely for COVID-related treatment, testing, or vaccination, making it difficult to assess how non-COVID care compares to the amount of care people received pre-pandemic. It is likely that utilization of some services, particularly for non-COVID care, remains below expectations based on pre-pandemic trends.

The chart collection is available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.