Inside the $1.9 trillion American Rescue Plan Act of 2021 is a less noticed provision that makes a major change to Medicaid coverage for low-income pregnant and postpartum women, addressing a long-standing gap for people who have had their maternity care covered by Medicaid, especially those in states that have not expanded Medicaid as permitted by the ACA. While the Act adds new incentives for states to take up the ACA Medicaid expansion, it also now gives all states the new option to extend the postpartum coverage period under Medicaid from 60 days following pregnancy to a full year. This post explains the new policy and raises some questions that policymakers are likely to grapple with as the implementation unfolds.

What does the new policy do?

• The American Rescue Plan Act of 2021 gives states a new option to extend Medicaid postpartum coverage from 60 days to 12 months. Currently, Medicaid covers almost half of births nationally, with eligibility levels ranging from 138% to 380% of poverty across states. States must cover pregnant women with incomes up to 138% of the federal poverty level (FPL) through 60 days postpartum (the end of the month of the 60^th postpartum day). The American Rescue Plan Act allows states to extend the postpartum period to a year by filing a State Plan Amendment (SPA) to their Medicaid program.
• Under the new law, the postpartum coverage duration can also be lengthened under the CHIP program. Currently, six states cover some low-income pregnant women through their CHIP programs. If a state takes up the new option to extend the postpartum period, this will apply to their CHIP coverage in addition to Medicaid.
• States that elect the new option must provide full Medicaid benefits during pregnancy and the extended postpartum period. Currently, states are permitted to cover a more narrow set of pregnancy-related benefits to those who qualify under the pregnancy pathway, although most align their benefits with other Medicaid eligibility groups. States that elect this new option however would have to provide full Medicaid benefits.
• The new option can take effect starting April 1, 2022 and would be available to states for five years. While the new option takes effect next year, currently postpartum women covered by Medicaid can remain on the program beyond 60 days because of a Maintenance of Effort requirement enacted in 2020 that lasts through the COVID public health emergency.

Questions going forward

• Which states will take up this option? While we do not know which states will take up the option, several have shown interest in extending the postpartum coverage period beyond 60 days. Some states have applied and have waivers pending at CMS to extend postpartum coverage. This includes expansion states like Illinois and New Jersey as well as non-expansion states like Georgia (which applied for extension through 180 days postpartum). These states could now file a SPA instead of waiting for approval of their waivers. Some states may decide to change earlier proposals. For example, Missouri has submitted a waiver application to CMS that would extend postpartum coverage to a year just for substance use and mental health services. That proposal would not qualify for the new SPA option because it would not cover full benefits.
• What will be the impact on women’s coverage in non-expansion states? Non-expansion states that take up the option could see a decrease in the share of low-income mothers who are uninsured. Medicaid income eligibility levels for parents are much lower than for pregnant people (Figure 1). Currently, in non-expansion states, some new mothers fall into the coverage gap where their incomes are too high for Medicaid parent eligibility yet too low for Marketplace subsidies (which are available only at the poverty level or above), putting them at risk for becoming uninsured.

• Will this option be adopted by expansion states? In states that have expanded Medicaid under the ACA, most postpartum women have a pathway to coverage – either Medicaid or subsidized private insurance through the ACA Marketplaces, but a longer postpartum period could allow for greater continuity with Medicaid providers. Studies have documented that new moms who have Medicaid funded childbirths experiencing significant churning in coverage.
• What will be the impact on federal and state budgets? The Congressional Budget Office (CBO) estimates that by 2024, about a quarter of postpartum beneficiaries will live in states that elect the new option. CBO estimates that extended Medicaid coverage will result in almost $6.1 billion in federal spending over the first ten years. States that adopt this extension would also incur costs as the extended coverage would remain at the same federal matching level, which ranges from 56.2% to 84.51%. These estimates take into account potential shifts in private insurance enrollment, including lower ACA subsidy costs. It is not clear if the estimates account for factors such as greater access to preventive services like contraception, which could avert unintended pregnancies that would otherwise be covered by Medicaid.
• What will be the impact on health outcomes? Part of the motivation for postpartum extension is the nation’s high rate of preventable pregnancy-related mortality and morbidity, particularly the stark disparities among Black and Native American women. There is also growing recognition that the postpartum period extends far beyond 60 days. Many of the conditions that account for a significant share of pregnancy-related mortality and morbidity, such as cardiovascular diseases, hypertension, and depression often require care over a longer-term. Providing Medicaid access to low-income mothers for a longer period also promotes continuity and access to preventive services such as contraception and intrapartum care.–The role of coverage as a key element of reproductive health care access is well understood. However, maternal health is also heavily connected to a complex set of issues, particularly poverty and systemic racism that pervade the health care system.

Ensuring widespread global access to COVID-19 vaccines, which is necessary for preventing cases and deaths and contributing to global population immunity, is a critical challenge and one that could threaten the ability to control the pandemic. Despite efforts to address vaccine access, most notably through the creation of COVAX, which aims to support the development and delivery of COVID-19 vaccines with a particular focus on assisting low- and middle-income countries, significant disparities remain. The latest data from the Duke Global Health Innovation Center Launch and Scale Speedometer, which monitors COVID-19 vaccine purchases, finds that high-income countries already own more than half of all global doses purchased, and it is estimated that there will not be enough vaccine doses to cover the world’s population until at least 2023.

To further examine the current global distribution of COVID-19 vaccine doses, we used data from the Duke Launch and Scale Speedometer to calculate the share of doses purchased by country income group compared to their share of the global adult population (focusing on adults, ages 18+, because most COVID-19 vaccines are thus far only available for the adult population). In addition, we calculated potential vaccine coverage rates – that is, the share of the adult population that could be fully vaccinated – by country income group. To do so, we reapportioned doses secured through regional agreements to their respective country recipients and added these to individual country totals where bilateral agreements were also in place. While it is not possible to allocate most COVAX doses purchased to individual countries at this time, since COVAX has yet to release its full distribution plan, we did assess how allocating  all COVAX doses to low- and middle-income countries (LMICs) would affect these distributions (see Methodology for more detail). Ultimately, we find that without redistribution of doses already purchased by high-income countries (through donations or other means) and/or increased support for manufacturing or production of additional doses, more than four in ten (41%) adults in the world will not be able to be vaccinated, even after allocating all COVAX doses to LMICs.

High-income countries, representing just a fifth of the global adult population, have purchased more than half of all vaccine doses, resulting in disparities between adult population share and doses purchased for all other country income groups. We find that although high-income countries only account for 19% of the global adult population, collectively, they have purchased more than half (54%, or 4.6 billion) of global vaccine doses purchased to date. Of the remaining doses, 33% have been purchased by LMICs, who account for 81% of the global adult population; an additional 13% have been purchased by COVAX. Looking by country income group, the largest disparity between doses purchased and population share is for lower-middle-income countries (37% of the global population vs. 12% of purchased doses, or 989 million doses), followed closely by upper-middle-income countries (37% vs. 18%, or 1.5 billion doses). The disparity for low-income countries is smaller (3% vs. 7%, or 263 million doses) (see Figure 1a).

The disparity is even more pronounced when looking at the share who could be vaccinated. While enough vaccine doses have been purchased to cover more than 80% of the adult population, high-income countries own enough doses to vaccinate more than twice their populations while LMICs can only cover one-third.

High-income countries currently have enough vaccine doses to cover more than twice their adult populations (245% see Figure 2a). Meanwhile, LMICs currently only have enough vaccine doses to reach approximately one-third of their populations, with upper-middle-income countries able to cover 39% of their adult population, low-income countries 38%, and lower-middle-income countries 27%.

Providing all COVAX doses to LMICs could help but would still leave vaccines out of reach for most of the global population. COVAX, which currently accounts for 13% (1.12 billion) of the total number of global doses purchased, has not yet finalized the distribution plan for its full supply, though most doses are expected to be distributed to LMICs. We looked at what would happen to global distribution, relative to population and to vaccine coverage, if all 1.12 billion COVAX doses were provided to LMICs (which is not going to be the case since some will go to high-income countries). While this would result in the share of doses purchased for LMICs increasing from 33% to 46%, it would still be well below their share of the global adult population (81%) (see Figure 1b). Moreover, even with the COVAX doses, less than half (49%) of the adult population in LMICs would be able to be vaccinated (see Figure 2b). Looking at potential global coverage rates, allocating all COVAX doses to LMICs only slightly improves the picture, increasing the percentage of adults globally that can be vaccinated from 46% to 59%. This is well below the percentage of adults globally that could be vaccinated based on the total number of doses purchased (86%) (see Figure 3).

The disparity between vaccines purchased and country income level is significant, but could be addressed in large part through redistribution of doses, as some high-income countries have said they would do. However, such a strategy is highly dependent on the as-of-yet unknown outcomes of several vaccine candidate trials or a significant increase in the manufacturing and production of already authorized vaccines. This analysis demonstrates the significant disparity in vaccine access across much of the world, at least of doses purchased to date. While high-income countries have secured enough doses for more than twice their adult population, LMICs currently have only enough doses to vaccinate just a third, or, if all COVAX doses were allocated to them, still less than a half. Although there are currently enough purchased doses to vaccinate more than 80% of the global adult population, unless these doses are redistributed, huge inequities in vaccine distribution will persist, presenting a major challenge to achieving global population immunity. Some high-income countries have indicated that they will donate their excess doses, including France, Norway, the U.K., and the U.S. government, which has said it will do so only after it has vaccinated the U.S. population. Still, even if such donations were to occur, their ability to fully address these disparities is in part dependent on the success of some vaccine candidates still in clinical trials or the ability to support the increased manufacturing of or production capacity for already successful vaccine products.

The American Rescue Plan (ARP), recently signed into law by President Biden, increases and expands eligibility for Affordable Care Act (ACA) premium subsidies for people enrolled in marketplace health plans. The law also creates new, temporary premium subsidies for COBRA continuation coverage; and it temporarily changes the rules for year-end tax reconciliation of marketplace premium subsidies. These changes will improve the affordability of coverage for individuals who are already enrolled in marketplace health plans, and will provide millions more an opportunity to newly sign up for coverage with increased financial assistance this year.  The law also made changes to the Medicaid program designed to increase coverage, expand benefits, and adjust federal financing.

Expanded Marketplace Premium Subsidies

Under ARP, ACA marketplace premium subsidies are substantially enhanced for people at every income level and, for the first time, offered to those with income above 4 times the federal poverty level (FPL).

People up to 150% FPL can now get silver plans for zero premium with vastly reduced deductibles. Previously, marketplace premium subsidies were partial; no matter how poor, people had to contribute something toward the cost of the benchmark silver plan (i.e., the second lowest cost silver plan in their area).  Those with income at 100% FPL had to contribute 2.07% of household income ($264 per year in 2021) toward a benchmark plan; at 150% FPL that amount increased to 4.14%  of household income( $792 per year).  Now under ARP, the benchmark marketplace plan will be fully subsidized for people earning up to 150% FPL.  Cost sharing subsidies were already most generous at this income level (the average silver plan deductible for people at 150% FPL is $177 this year). As a result, low income people now can qualify for premium-free silver plans with modest deductibles for covered health benefits.

Premium subsidies will also increase for people at higher income levels among those currently eligible for help with incomes up to 400% of the poverty level. Premium tax credits will increase for people at every income level. (Figure 1) People with income of 200% FPL had been required to contribute $1,664 toward the cost of the benchmark marketplace plan this year; now under the ARP they will have to contribute just $510. At income of 400% FPL, people were required to contribute up to $5,017 toward the benchmark plan premium, now they will be required to contribute no more than $4,338 toward that plan.

People with income above 400% FPL will be newly eligible for marketplace premium subsidies. Under the ACA, people with income above 400% FPL were not eligible for marketplace premium subsidies. Now, they will be required to contribute no more than 8.5% of household income toward the benchmark plan. This change will provide limited relief to younger marketplace participants – for example, for 24-year-olds in most areas, the unsubsidized age-rated benchmark plan premium already costs less than 8.5% of income for someone at 401% FPL – but will offer substantial relief for older individuals, where the unsubsidized premium averages nearly 25% of household income for someone at that same income level who is 64 years old. (Figure 2) Before this change, when they were ineligible for premium subsidies, some people with income above 400% FPL bought their insurance outside of the marketplace, or bought non-ACA compliant plans (such as short term policies). These individuals may want to return to the marketplace where coverage may now be more affordable and more comprehensive. The Biden Administration has reopened marketplace enrollment through May 15.

The ARP premium subsidy enhancements are effective during 2021 and 2022. These changes to marketplace premium subsidies are temporary, in effect only during calendar years 2021 and 2022. The specifics and timeline for implementation of these changes is yet to be determined. However, once implemented, current enrollees may be able to sign into their marketplace account to increase the amount of advanced premium tax credit (APTC) they receive, thereby lowering their monthly health plan premium payment for the remainder of this year. Subsidies for current enrollees are retroactive to the beginning of this calendar year and can also be claimed as tax refunds when people file their 2021 tax return next year.

In HealthCare.gov states, current enrollees will also be able to change plans during the COVID enrollment period, which currently extends through May 15, 2021. People covered in state-based marketplaces should check with their marketplace for information about their ability to change plans as the new premium subsidies are implemented. Presently, some state-based marketplaces offer a COVID enrollment period when only uninsured individuals can sign up.

Enhanced Subsidies for Unemployed People

The ARP provides for enhanced marketplace subsidies for people who receive or are approved to receive unemployment insurance (UI) benefits during any week in 2021. The ARP also extends the current federal supplement ($300 per week) to state UI benefits through September 6, 2021. The federal UI supplement is not taken into account in determining eligibility for Medicaid or CHIP.

When UI recipients apply for marketplace subsidies, special rules will be in effect during 2021.

Household income in excess of 133% FPL will be disregarded for purposes of determining eligibility for marketplace premium and cost sharing subsidies in 2021. As a result, people who receive UI benefits at any time in 2021 will be eligible for a zero-premium benchmark silver plan with comprehensive cost sharing subsidies this year.

People receiving UI benefits will be considered “applicable taxpayers” during 2021. Normally under the ACA, to be eligible for marketplace subsidies, a person must qualify to be an “applicable taxpayer” which requires having an income of at least 100% FPL. Under the ARP, for 2021 only, people who receive UI benefits are defined to be an applicable taxpayer. That can help some UI recipients with income below the federal poverty level who live in states that have not adopted the ACA Medicaid expansion; they were otherwise in the “coverage gap,” ineligible for both Medicaid and marketplace subsidies.

These enhanced marketplace subsidies for UI recipients are only for the 2021 coverage year.Congress would need to enact further legislation to extend UI subsidy enhancements beyond this year.

People receiving UI benefits will still have to meet other requirements to be eligible for marketplace subsidies. In particular, married individuals must file a joint return to be eligible for subsidies. Using the married-filing-separately filing status generally makes a person ineligible for subsidies, though an exception is available for people who experience domestic abuse.

In addition, people receiving UI benefits may still be ineligible for marketplace subsidies if they have access to job-based health benefits that meet ACA standards for affordability and minimum value. The affordability of job-based coverage will continue to be measured based on household income, including UI benefits and amounts above 133% FPL.

Premium Tax Credit Repayment Holiday for 2020

When people apply for marketplace premium subsidies, they do so based on their estimated annual income for that tax year. Later, when they file federal tax returns for that year, people must reconcile their actual income with the amount of premium tax credit they received based on estimated income, and repay some or all of any excess premium tax credit (or receive an additional credit if actual income was lower than anticipated). Caps on the repayment amount apply, but if actual income exceeds 400% FPL, people must repay the entire amount of excess premium tax credit they received during the year.

Recognizing that the pandemic caused greater-than-usual economic disruption and uncertainty in 2020, the ARP waives repayment of any excess premium tax credit received by marketplace participants during that year.

Implementation questions remain to be addressed. Before the ARP was enacted, the Internal Revenue Service (IRS) had already finalized 2020 tax forms and schedules, which provide for APTC reconciliation and repayment of excess credits. Further action by the IRS will likely be forthcoming to educate the public about this new protection, advise on how to use it when filing the 2020 tax return, and to refund amounts to people who may have already filed their 2020 tax return with repayments.

Temporary COBRA Premium Subsidies for 2021

The ARP provides for temporary COBRA premium subsidies for up to 6 months during 2021. Subsidies will cover 100% of the monthly cost of COBRA while people are eligible. The law requires the former employer to pay the COBRA premium for subsidy-eligible individuals; the federal government will then reimburse the former employer for this cost.

The COBRA premium subsidies can be paid for coverage months no earlier than April 1, 2021 and no later than September 30, 2021. The subsidy can end earlier than September 30 in some circumstances.  It ends when COBRA coverage is exhausted; so for example, someone who first became eligible for COBRA due to a job layoff on March 1, 2020 could continue in that plan for 18 months, or through August 2021.  That person could claim the COBRA premium subsidy starting in April 2021, but the subsidy would stop when COBRA exhausts at the end of August.  People also lose eligibility for the COBRA premium subsidy once they become eligible for other job-based coverage.  If this happens, people must notify their COBRA plan administrator or risk owing a penalty.   

The subsidy is for people whose COBRA qualifying event involves termination of employment or reduction in hours worked. People are not eligible for the COBRA subsidy if they quit voluntarily. Nor are they eligible for subsidies if COBRA resulted from other qualifying events, including death of or divorce from the covered employee, the covered employee becoming entitled to Medicare, or loss of dependent child status.

People who became eligible for COBRA earlier in the pandemic can still elect it. Normally, people have up to 60 days from their qualifying event to elect COBRA continuation coverage. During the pandemic, however, people have additional time to elect COBRA, thanks to a COVID disaster relief notice issued by the Departments of Labor and Treasury. Their new COBRA election deadline will be the earlier of (1) one year from the date the person’s election period would otherwise have ended, or (2) 60 days after the announced end of the COVID National Emergency. For example, a person who was laid off early in 2020 and whose deadline for electing COBRA was April 1, 2020 can now take until April 1, 2021 to elect COBRA. Going forward, a person who becomes newly eligible for COBRA can have her election period extended by up to 1 year (or until 60 days following the end of the National Emergency, whichever is earlier.) This emergency rule applies to election of COBRA arising from all qualifying events.

People who became eligible for COBRA earlier in the pandemic can have coverage start prospectively. Normally, once elected, COBRA coverage dates back to the qualifying event and premiums have to be paid retroactive to that point in time. This will remain the rule for subsidy-eligible people whose qualifying event occurs on or after April 1, 2021

However, under the ARP a special rule applies for subsidy-eligible individuals whose COBRA qualifying event pre-dates enactment of the ARP and who have not yet elected COBRA; or for such individuals if they previously elected COBRA but subsequently discontinued it, and who otherwise remain eligible for COBRA. When these individuals elect COBRA, coverage will commence on the first day of April 2021. Their COBRA coverage will not extend back in time before that date and they will not owe COBRA premiums prior to that date.

Eligible individuals who were already paying for COBRA when the law passed can also claim the subsidy.

COBRA premium subsidies are not counted as income to the individual. Subsidies will not affect a person’s tax liability or eligibility for other income-related benefits.

People eligible for COBRA subsidies may also be eligible for marketplace subsidies or Medicaid. Just being eligible for COBRA does not affect a person’s eligibility for marketplace subsidies or Medicaid. Those who have a choice will want to weigh their out of pocket costs (for premiums and cost sharing, net of subsidies), as well as any differences in plan provider networks, covered benefits, and other plan features. Generally, once a person enrolls in COBRA, she won’t have an opportunity to choose marketplace coverage again until the earlier of the next open enrollment period or the date when she exhausts COBRA coverage.

When COBRA premium subsidies end, people can continue unsubsidized enrollment in COBRA. Of course, for many, unsubsidized COBRA may prove unaffordable. Generally, if a person terminates (or stops paying the premium for) COBRA before it exhausts, this loss of coverage does not make a person eligible for a special enrollment period (SEP) in the marketplace.

However, the marketplace has broad authority to recognize new SEP qualifying events. It remains to be seen if HealthCare.gov and state-based marketplaces will recognize termination of COBRA premium subsidies as a qualifying event and allow people the option to switch to more affordable marketplace plans and subsidies at that time.

Other ARP Changes and Affordability

Stimulus payments – The ARP provides for stimulus payments up to $1,400 for qualifying individuals in 2021. These payments are considered tax credits and are not counted as income for purposes of tax liability or eligibility for income-based programs and benefits.

Exemption of UI benefits from federal income tax in 2020 – The ARP also included a provision exempting the first $10,200 in UI benefits paid to an individual in 2020 from inclusion in that individual’s adjusted gross income for that year, which will also lower countable income for the purposes of marketplace premium subsidies. As a result of this change, people who participated in the marketplace in 2020 may find they were eligible for greater premium tax credits than they claimed during the year. If so, people can receive unclaimed 2020 APTC as a refundable tax credit when they file their 2020 federal income tax return. People who already filed their 2020 return before the law was enacted should be able to claim the refund, as well.

Next steps?

These significant changes to make private coverage more affordable were enacted after many people had already enrolled in 2021 marketplace plans, after HealthCare.gov and state-based marketplaces had announced a time-limited special COVID enrollment opportunity, and after the 2020 tax filing season was underway. It will take time for federal and state agencies to implement these changes, including updates to marketplace subsidy eligibility systems, drafting of model notices, and revision of tax forms. The Department of Health and Human Services has announced that the enhanced ACA premium subsidies will be available through HealthCare.gov beginning April 1, but other changes in the ARP may take more time. Under the current special COVID enrollment period, people will have until May 15 to newly sign up for coverage or change plans to take advantage of the additional help.

On March 11, 2021, President Biden signed the American Rescue Plan Act of 2021 (P.L. 117-2), a $1.9 trillion stimulus package, into law.  Among other things, this latest relief bill, the nation’s sixth, infuses new funding for critical COVID-19 public health activities, including vaccine distribution, testing, contact tracing, surveillance, and the public health workforce, building on prior emergency relief funding provided by Congress (other provisions of the bill expand the Affordable Care Act by making marketplace and private health insurance more affordable and by providing new incentives to states that have not yet expanded their Medicaid programs to do so). Funding for COVID-19 public health focused activities in the bill totals almost $93 billion, most of which has been made available until expended. The main public health provisions are as follows:

• $7.5 billion (Section 2301) to the Secretary of Health and Human Services (HHS) to provide to the Centers for Disease Control and Prevention (CDC) for COVID–19 vaccine distribution and administration, including support for State, local, Tribal, and territorial public health departments. Activities include the establishment and expansion of community vaccination centers and mobile vaccination units, particularly in underserved areas; reporting enhancements; communication efforts; and transportation of individuals to vaccination, particularly underserved populations.
• $1 billion (Section 2302) to HHS to provide to CDC for vaccine confidence, information, and education activities.
• $6.05 billion (Section 2303) to HHS to support the supply chain for COVID-19 vaccines, therapeutics, and ancillary medical products through research, development, manufacturing, production, and purchasing
• $500 million (Section 2304) to the Food and Drug Administration (FDA) for activities related to COVID-19 vaccines, therapeutics, and diagnostics, including for evaluation of their continued performance, safety, and effectiveness and facilitation of advanced continuous manufacturing.
• $47.8 billion (Section 2401) to HHS for testing, contact tracing, surveillance, and mitigation activities, including for the development of a national evidence-based strategy, support for State, local, and territorial public health departments, support for development, manufacturing, procurement, distribution, and administration of tests, and to establish and expand Federal, State, local, and territorial testing and contact tracing capabilities.
• $1.75 billion (Section 2402) to HHS to be provided to CDC for SARS-CoV-2 genomic sequencing and surveillance, including support for State, local, Tribal, or territorial public health departments or public health laboratories.
• $500 million (Section 2404) to CDC for data modernization and forecasting.
• $7.66 billion (Section 2501) to HHS for the public health workforce, including support for State, local, and territorial public health departments to hire case investigators, contact tracers, social support specialists, community health workers, public health nurses, disease intervention specialists, epidemiologists, program managers, laboratory personnel, informaticians, communication and policy experts, and any other positions as may be required to prevent, prepare for, and respond to COVID–19 and to provide PPE.
• $100 million (Section 2502) to HHS for the medical reserve corps.
• $7.6 billion (Section 2601) to HHS for community health centers for activities including COVID-19 vaccine distribution and administration, testing, contact tracing, mitigation, workforce enhancement, and community outreach and education.
• $10 billion (Section 3101) to enhance use of the Defense Production Act for the purchase, production, or distribution of medical supplies and equipment for COVID-19 including for testing, PPE, vaccines and other drugs and biological products.
• $2.34 billion (Section 11001) to the Indian Health Service for COVID-19 vaccine distribution and administration ($600 million); testing, contact tracing and mitigation ($1.5 billion); and public health workforce for COVID-19 ($240 million).

Summary

Even as the COVID-19 vaccine roll-out is accelerating across the country, the public health and economic effects of the pandemic continue to put pressure on Medicaid spending and enrollment. In mid-February 2021, the Kaiser Family Foundation (KFF) and Health Management Associates (HMA) fielded a two-part rapid, mini-survey of Medicaid directors in all 50 states and the District of Columbia as a follow-up to the annual Medicaid Budget Survey conducted last summer. This brief provides insights into the current status of Medicaid enrollment and spending trends in FY 2021 and state projections for FY 2022. See separate brief for findings from Part II of this mini-survey, related to state Medicaid agency involvement with the COVID-19 vaccination roll-out. A total of 38 states responded to the Part I enrollment and spending survey, although not all of these states answered all of the survey questions. These states accounted for over three-quarters of total Medicaid enrollment.¹  For most states, the state fiscal year begins on July 1. Key findings include the following:

• Most states with updated Medicaid enrollment projections expect overall FY 2021 enrollment to exceed original projections (30 of 37 states). Most states reported that expansion adults and other adults had the highest rates of growth. Two-thirds of states with updated Medicaid expenditure projections for FY 2021 (24 of 37 states) also expect total FY 2021 Medicaid expenditures to exceed original projections.
• Looking ahead to FY 2022, just under half of responding states (12 of 29) are projecting a higher total Medicaid expenditure growth rate in FY 2022 compared to FY 2021, while just over half (14 of 29) are expecting the growth rate to be lower. While fewer states reported specific FY 2022 spending growth rate percentages, the median rate for 21 reporting states was 5.6% while the median projected enrollment growth rate for 17 reporting states was 5.5%. Most states with updated projections assumed that the public health emergency (PHE) would remain in effect through CY 2021, part-way through the state fiscal year.

Medicaid spending and enrollment trends will continue to depend on the trajectory of the pandemic and the economic downturn as well as the duration of the PHE. In particular, the expiration of the PHE and the enhanced FMAP will have implications for state spending during the 2022 fiscal year.

Background/Context

The coronavirus pandemic has generated both a public health crisis and an economic crisis, with major implications for Medicaid, a countercyclical program. During economic downturns, more people enroll in Medicaid, increasing program spending at the same time state tax revenues may be falling. To help support states as Medicaid enrollment grows and ensure continuous coverage for enrollees, the Families First Coronavirus Response Act (FFCRA) authorized a 6.2 percentage point increase in the federal match rate (“FMAP”) for states that meet certain “maintenance of eligibility” (MOE) requirements. The additional funds were retroactively available to states beginning January 1, 2020 and continue through the quarter in which the PHE period ends. While the current PHE declaration expires on April 21, 2021, the Biden Administration has notified states that the PHE will likely remain in place throughout CY 2021 and that states will receive 60 days-notice before the end of the PHE to allow states time to prepare for the end of emergency authorities and the resumption of pre-PHE rules.

After relatively flat Medicaid enrollment growth in FY 2020 (0.4%), states responding to KFF’s annual Medicaid Budget Survey conducted in June-August 2020, projected, on average, that Medicaid enrollment would increase 8.2% in FY 2021 (over FY 2020) and total spending would increase by 8.4%. Preliminary national data show that total Medicaid and CHIP enrollment grew to 77.3 million in September 2020, an increase of 6.1 million, or 8.6%, from February 2020. This growth likely reflects both changes in the economy, as more people experience income and job loss and become eligible and enroll in Medicaid coverage, and the FFCRA MOE provisions that require states to ensure continuous coverage for current Medicaid enrollees through the end of the month in which the PHE ends. This growth represents a reversal of recent Medicaid enrollment trends in 2016 through 2019, when the rate of total Medicaid and CHIP enrollment growth was declining or negative.

All states are experiencing fiscal stress tied to the pandemic, although individual state experiences vary. The impact of the pandemic on states depends on a variety of factors including the composition of state economies, tax structures, and virus transmission levels, among other factors. For example, states that are more dependent on tourism and the energy sector have seen larger economic and state revenue impacts. Overall, however, state revenues declined in FY 2020 and greater declines are expected in FY 2021. As a result, states’ enacted budgets for FY 2021 reflect the first general fund spending decrease in more than ten years as states make reductions to meet balanced budget requirements. While the state fiscal relief provided by FFCRA has undoubtedly helped states avoid more severe budget cuts, some states still face budget gaps that they must address. While states often turn to provider rate and benefit restrictions to constrain Medicaid spending during economic downturns, these cost containment approaches may not be as viable with providers facing revenue shortfalls and enrollees facing increased health risks due to the pandemic.

KEY FINDINGS

Enrollment

Most states with updated Medicaid enrollment projections expect overall FY 2021 enrollment to exceed original projections (30 of 37 states) with higher growth rates reported for expansion and other adults. We asked states to identify the eligibility group (children, parent/caretakers, expansion adults, persons with disabilities, or seniors) that has experienced the highest rate of enrollment growth in FY 2021 (Figure 1). A majority of responding states that had implemented the ACA Medicaid expansion as of February 2021 (22 of 28) indicated “expansion adults” have experienced the highest rate of enrollment growth in FY 2021 while four expansion states identified “parent/caretakers” and two expansion states identified “children.” Among the 10 responding non-expansion states, seven states indicated “parent/caretakers” have experienced the highest enrollment growth in FY 2021 while three states indicated “children.” No states reported seniors or persons with disabilities as groups experiencing the highest rate of enrollment growth. Nonelderly adults are more likely to be affected by changes in the economy and more likely to experience churn on and off the program that the FFCRA MOE has eliminated during the PHE.

The median growth rate for the 17 states reporting Medicaid enrollment growth projections for FY 2022 over FY 2021 is 5.5%. We asked states whether their projections accounted for the likelihood that the PHE and continuous coverage requirements would remain in place through CY 2021 as indicated in a January 2021 Biden administration letter to Governors. More than half of the responding states indicated that their projections reflect the PHE remaining in place throughout 2021, followed by a gradual enrollment decline beginning in CY 2022 after the expiration of continuous coverage requirements (during the second half the state fiscal year for most states). Several states indicated that their projections did not assume that the PHE and continuous coverage requirements would remain in place through the end of CY 2021 suggesting that the projections were developed prior to the release of the Biden Administration letter or that some states may not consider the letter to reflect enough certainty. Based on these assumptions, these states generally reported lower expected enrollment growth for FY 2022 than states that assumed the PHE would continue through CY 2021. To the extent that the PHE remains in place longer, actual enrollment could be higher than projected. In addition to uncertainty regarding the PHE end date, states cited other currently unknown factors that could significantly affect the accuracy of current FY 2022 enrollment projections such as future trends in unemployment and the Medicaid enrollment impacts of the ACA special enrollment period.

Expenditures

Almost two-thirds of states with updated Medicaid expenditure projections for FY 2021 (24 of 37) expect total FY 2021 Medicaid expenditures to exceed original projections (Figure 2). Nearly all of these states (23 of 24) indicated higher enrollment as the most significant driver of FY 2021 Medicaid expenditures so far. States attributed increases in enrollment to both the economic downturn and to the FFCRA MOE requirements. In contrast, about one third of states with updated FY 2021 projections expect total Medicaid expenditures to be lower than (7 of 37) or about the same as (6 of 37) earlier projections. Four states expecting lower FY 2021 total Medicaid expenditures attribute decreases to net decreases in utilization; three of these states deliver Medicaid services to enrollees through fee-for-service delivery systems where net decreases in utilization immediately result in lower Medicaid expenditures. While utilization may have been initially depressed in FY 2021 due to enrollees foregoing or providers limiting non-urgent care, some states commented that utilization was starting to rebound. Decreases in utilization in heavily capitated managed care states may not result in lower expenditures unless states adjust capitation rates.

Although many states’ updated FY 2021 total Medicaid expenditure projections exceed the projections originally made at the beginning of the state fiscal year, nine of 38 states reported mid-year cost containment policy actions. Three states indicated implementing mid-year provider rate cuts, and although not specifically asked about provider taxes, one state reported that they implemented a new provider tax in 2021. Eight states indicated making mid-year managed care plan rate adjustments. However, several states also commented that MCO contracts were amended to add risk mitigation strategies (e.g., risk corridors). One state reported implementing mid-year benefit restrictions, and one state reported several benefit expansions passed by the state legislature in 2020 were removed before implementation. The survey did not ask about the effects of the federal fiscal relief, but states had reported in an earlier survey that the fiscal relief helped to mitigate Medicaid cuts and address Medicaid shortfalls.

Of the 29 states with expenditure projections for next fiscal year, half anticipate that total Medicaid expenditure growth in FY 2022 will slow down compared to FY 2021 while just under half expect the rate to accelerate (Figure 2). Three states expect the rate of spending growth to be “about the same.” The median growth rate for the subset of states (21) reporting actual growth rates for FY 2022 is 5.6% (over FY 2021). While we only asked about total spending projections, state spending growth is likely to accelerate in FY 2022 when the PHE and enhanced FMAP expire, as states will need to replace the expiring federal funds with state funds.

About one-third of responding states (12 of 38) reported plans to introduce cost containment policy actions in FY 2022. Six states plan to introduce provider rate cuts in FY 2022, seven states plan to make MCO rate adjustments, and three states plan to introduce benefit restrictions. Other planned FY 2022 cost containment strategies/actions reported by states include expansion of value-based payment initiatives, new utilization management strategies, and the introduction of risk-based managed care. Similar to the mid-year cost containment strategies reported for FY 2021, several states reported plans to introduce (or continue) capitated managed care plan risk mitigation strategies (e.g., risk corridors) and at least one state plans to implement revenue generating provider fees. Fourteen states reported that no cost containment policy actions are planned for FY 2022, nine states reported that FY 2022 actions are undetermined, and three states responded, “don’t know.”

Looking Ahead

As states approach the end of FY 2021 and adopt budgets for FY 2022 (that begins in July for most states), they must account for the ongoing impacts of the pandemic and resulting economic downturn on Medicaid spending and enrollment trends. While substantial enrollment growth has already occurred across all states, more growth is possible as individuals continue to struggle with the economic downturn and due to the decision to open enrollment in the federal ACA Marketplaces from February 15 through May 15, combined with $50 million in federal spending on outreach and education about ACA coverage options. This outreach has the potential to reach millions of people who became uninsured prior to or during the pandemic and will likely result in more eligible low-income people enrolling in Medicaid. State spending and enrollment projections must also account for the expiration of the PHE. At that time, states will resume eligibility renewals and redeterminations, possibly leading to slower enrollment growth and decreased total spending growth. The end of the PHE, however, will also end the enhanced FMAP requiring states to increase state spending to replace the expiring federal funds. Finally, even if total Medicaid spending growth is lower in FY 2022 relative to 2021, median growth rates in excess of 5 percent may difficult to absorb, depending on how quickly the economy and state revenues recover.

1. The 13 states that did not respond were: Arkansas, the District of Columbia, Georgia, Hawaii, Idaho, Louisiana, New Hampshire, New Jersey, New Mexico, Ohio, Texas, Utah, and Vermont. ↩︎

As of February 2021, there are three COVID-19 vaccines approved for emergency use in the U.S. and states are playing a central role in their timely distribution and prioritizing eligible populations. Because Medicaid covers for over 77 million enrollees, including groups disproportionately at risk of contracting COVID-19 as well as hard-to-reach groups, Medicaid agencies can be important partners for the public health agencies that are typically leading the state COVID-19 vaccination efforts. In mid-February 2021, the Kaiser Family Foundation (KFF) and Health Management Associates (HMA) fielded a two-part rapid, mini-survey of Medicaid directors in all 50 states and the District of Columbia. Of the 32 states that responded to Part II of the survey, 29 reported that Medicaid agencies were involved in at least one vaccine roll-out activity (Figure 1). This brief provides insights regarding how state Medicaid agencies are assisting with the COVID-19 vaccine roll-out including specific actions taken. (See separate brief for findings from Part I of the mini-survey related to Medicaid enrollment and spending trends.)

Three-quarters of responding states (24 of 32) reported partnering with public health or other agencies to plan and implement the vaccine roll-out. Several states indicated close coordination with their state departments of public health that are taking the lead on vaccine distribution and roll-out. For example, one state commented that it amplifies the public health department’s messaging and communications, but also periodically relays back concerns from key Medicaid stakeholders (e.g., behavioral providers not included in the Phase 1a priority group for health care workers). Fewer states, however, reported being involved with determining state vaccination priority lists (11 of 32).

Over three-quarters of responding states indicated their state Medicaid agencies are providing technical assistance to providers (25 of 32). States reported communicating directly with Medicaid providers regarding the roll-out of COVID-19 vaccinations through, for example, provider bulletins and dedicated webpages that include information on COVID-19 vaccination coverage, reimbursement, and billing and a dedicated email address/inbox for provider questions. One state also reported that it has worked to ensure that there is an expedited process for vaccinators to enroll in Medicaid (if not already enrolled).

Over half of responding states reported conducting outreach to Medicaid enrollees to encourage COVID vaccination take-up (19 of 32). Several states discussed working with Medicaid managed care plans on vaccine roll-out activities including: messaging to address member vaccine hesitancy; clarifying the availability of MCO care coordination and transportation services that could reduce vaccine access barriers; coordinating COVID vaccine appointments; calling high-risk members, and making vaccination appointment reminder calls. Over half of responding states (17 of 32) are expanding services to assist with vaccine roll-out. For example, a few states specifically mentioned authorizing nonemergency medical transportation (NEMT) services for vaccine appointments. A number of states (12 of 32) also reported planning or authorizing new or expanded Medicaid administrative supports. One state, for example, commented that its existing nurse advice line will provide general information to callers regarding vaccine administration.   

The majority of responding states reported that the Medicaid agency is involved with specific activities to assist with vaccine roll-out to groups disproportionately covered by Medicaid. About two-thirds of responding states (22 of 32) reported that their state Medicaid agencies are involved with specific activities to assist with vaccine roll-out to HCBS recipients. About half of responding states also reported assisting with vaccine roll-out efforts for residents of non-nursing home institutions, communities of color, and people in rural areas (Figure 2). Several states commented on a number of specific activities underway including:

• Data sharing with the public health agency on seniors receiving HCBS who are not in a nursing facility or alternative living facility. The public health agency matched the data provided against its vaccine registry and is now conducting outreach to those not yet vaccinated.
• Developing quality measures focused on closing vaccination disparities between whites and communities of color.
• Proactively outreaching to NEMT drivers to get vaccinated and drive to vaccination events.
• Requesting federal approval to provide COVID-19 vaccines to populations who are in limited benefit programs (e.g., family planning program, COVID-19 uninsured group, and restricted scope programs where only emergency and pregnancy related services are offered).
• Partnering with Rite Aid to provide vaccinations to long-term care facilities not covered by the federal pharmacy partnership program.
• Encouraging MCOs to utilize community health workers to conduct outreach to individuals that are transient or difficult to reach, including individuals experiencing homelessness, people with disabilities, or individuals with substance use disorders.

More than three-quarters of states (26 of 32) indicated at least one way in which partnerships between public health and Medicaid had been or could be further developed to assist with vaccine roll-out efforts. The most common areas of opportunity reported were coordinating outreach, data sharing, and holding daily or weekly meetings between agencies. States described other activities that could assist in vaccine roll-out efforts including: creating opportunities to have staff work across agencies; coordinating to assist individuals without internet access and individuals whose first language is not English in scheduling vaccination appointments, and working to help ensure and promote equity regarding the vaccine roll-out.

Early data suggest significant racial disparities in COVID-19 vaccinations, with higher vaccination rates among White people compared to Hispanic and Black people as of early March, based on available state-reported data. The Biden administration has identified equity as a key priority in its national COVID-19 response strategy. One action the administration is pursuing to advance equity in vaccinations is to increase distribution through community health centers.

Community health centers are a national network of safety net primary care providers and are a primary source of care for many low-income populations and people of color. This analysis examines the extent to which early vaccination efforts through community health centers are reaching people of color using data from the federal government’s weekly Health Center COVID-19 Survey. We include data from the survey weeks of January 8 through February 26, 2021, largely before the start of the federal health center COVID-19 vaccination program.

Just over half (54%) of people who received their first dose of the COVID-19 vaccine from health centers were people of color, including 26% who were Hispanic and 12% who were Black. These shares are higher than the shares of nationwide vaccinations; show that 9% of people receiving one more dose of vaccine as of March 7, 2021 were Hispanic and 7% were Black. The shares of vaccinations received by people of color at community health centers increased in more recent weeks compared to vaccinations in January 2021.

The shares of people receiving the first dose of the COVID-19 vaccine at health centers who were Black, Hispanic, and Asian generally matched or exceeded their shares of the total population. However, their shares of vaccinations were similar or slightly lower than their shares of the overall health center patient population. Patterns of health center vaccinations by race/ethnicity compared to their population distributions varied widely by state.

While vaccinations at health centers represent a relatively small share of total vaccinations administered nationally to date, further ramping up health centers’ involvement in vaccination efforts at the federal, state, and local levels will likely be a meaningful step in reaching people of color and advancing equity on a larger scale.

Source

Community Health Centers’ Role in Delivering Care to the Nation’s Underserved Populations During the Coronavirus Pandemic

The latest report from the KFF COVID-19 Vaccine Monitor examines how the COVID-19 pandemic has impacted the lives of lesbian, gay, bisexual and transgender (LGBT) people and finds that larger shares of LGBT adults report economic losses and mental health struggles than their non-LGBT counterparts.

Based on data gathered on self-identified LGBT and non-LGBT individuals over two months, some of the key differences include:

• Economic impact. Most LGBT adults say that they or a household member lost a job or income due to the pandemic (56%), which compares to 44% of non-LGBT adults.
• Mental health. Three quarters (74%) of LGBT people say worry and stress from the pandemic has had a negative impact on their mental health, compared to half (49%) of non-LGBT people. LGBT people are also more than twice as likely to say this negative impact has been major (49% to 23%).
• Vaccine intentions. LGBT people are about as eager to get vaccinated as other Americans but more view it as a part of everyone’s responsibility to protect the public health (75%) rather than a personal choice (24%). Non-LGBT individuals are about as equally likely to say it is part of everyone’s responsibility (48%) and a personal choice (49%).

Differences in the experiences of LGBT and non-LGBT individuals likely reflect a number of factors. Other research has found that LGBT individuals are more likely to work in health care, restaurants and other industries highly impacted by the pandemic; have lower average incomes; and may experience discrimination and stigma, including in accessing health care.

The new report is available through the Monitor’s online dashboard.

This analysis is based on interviews conducted in December and January among a nationally representative random digit dial telephone sample of 3,239 adults, including 174 who identified as lesbian, gay, bisexual, or transgender. The margin of sampling error is plus or minus 9 percentage points for the full LGBT sample and 2 percentage points for the non-LGBT sample. For results based on subgroups, the margin of sampling error may be higher. Detailed methodology can be found in the toplines for the December and January KFF COVID-19 Vaccine Monitor.

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.