What Do the Early Medicaid Unwinding Data Tell Us?

What do the early data show?

As states begin to unwind the COVID emergency continuous enrollment provision and resume Medicaid disenrollments, early data from a handful of states – highlighted on KFF’s regularly-updated Medicaid Enrollment and Unwinding Tracker – reveal wide variation in disenrollment rates. While not all states that have resumed disenrollments have publicly posted their numbers, data from 12 states show that over half a million enrollees have already been disenrolled, nearly 250,000 in Florida alone (Figure 1). In nine states that reported both total completed renewals and total disenrollments, the disenrollment rate ranges from 54% in Florida to just 10% Virginia. Among these states, the median disenrollment rate is 34.5%.

The early data also reveal high rates of procedural disenrollments in some states reporting this break out. The share of procedural disenrollments – where people are disenrolled because they did not complete the enrollment process and may or may not still be eligible for Medicaid – exceeds 80% in Arkansas, Indiana, Florida and West Virginia, and was nearly 55% in Iowa (Figure 2). High procedural disenrollments raise concerns particularly in light of recent findings from a KFF survey that nearly two-thirds of current Medicaid enrollees said they did not have a change in income or circumstance in the past year that would make them ineligible for Medicaid. While it is possible that some people are not completing the renewal process because they have other coverage, the survey findings suggest many of the people whose coverage was terminated for procedural reasons in the past month likely remain eligible.

What are key questions to ask as more data become available?

These early data provide an important, but incomplete, picture of how the unwinding is unfolding across the states that have so far resumed disenrollments. Although CMS requires states to report monthly data on total renewals due, total individuals whose coverage was renewed, and total disenrollments, including for procedural reasons, only a handful of states have so far released these reports publicly. Other states have created dashboards, but the data states are reporting vary. In some cases, data are only for a subset of the total Medicaid populations or disenrollments are reported but without breakouts for procedural disenrollments. Having more consistent data from all states would help provide a clearer picture of how the unwinding is unfolding across states.

Is variation in how states are prioritizing renewals driving early differences in disenrollment rates?  In some states, including Arkansas, Idaho, Iowa, and Florida, early renewals are largely among people the states think are no longer eligible or who did not respond to renewal requests while the continuous enrollment provision was in place; these states generally have higher disenrollment rates compared to other states (except for Iowa). Other states, like Indiana, Nebraska, and Virginia, have instead adopted a time-based approach where they conduct renewals based on an individual’s renewal date. And still other states, such as Arizona, are including a mix of people they think are no longer eligible along with those whose scheduled renewal date is in the reporting month. State renewal policies and systems capacity may also play a role in the variation in disenrollment rates.

How can state communication and outreach efforts be improved to lower the rates of procedural disenrollments?  Despite broad efforts by many states to reach out to Medicaid enrollees in advance of the start of the unwinding, the messages may not have gotten through. The KFF survey findings also reveal that nearly two-thirds of Medicaid enrollees are not aware that states are now permitted to resume disenrolling people from the Medicaid program. In addition, nearly half said they had not previously actively participated in renewing their Medicaid coverage. Consequently, many enrollees may not know what to expect or how to complete the renewal process, which may be contributing to the high rates of procedural disenrollments in some states. States can continue to conduct outreach and engage more fully with key stakeholders to raise awareness throughout the unwinding period.

Will there be any way to track whether people who are disenrolled but remain eligible are able to reenroll in Medicaid? With such high disenrollment rates for procedural reasons, it is likely that some, possibly many, people who lose coverage continue to qualify for Medicaid. Some of these people may churn back onto the Medicaid program, but others may not regain coverage. Research indicates that about 10% of Medicaid enrollees churn in a normal year, while another analysis focused on children found that disenrollment and churn are higher at annual renewal. Moreover, most people who lose Medicaid coverage experience a period of uninsurance before reenrolling in Medicaid. Right now, however, only Pennsylvania appears to be tracking and reporting whether people who are disenrolled reenroll in Medicaid within four months.

Are any states providing data about what happens to individuals who are determined ineligible? There is also the question of whether people who are disenrolled because they are no longer eligible are able to obtain other coverage, particularly through the ACA Marketplaces, though potentially through employers as well. The Consolidated Appropriations Act requires states to report on the number of people who are transferred to the Marketplace and how many people enroll in a QHP. States that operate their own Marketplaces can provide this information, but so far, only Kentucky and Pennsylvania include this information on their state dashboards while Rhode Island reports the data will be included once it’s available. CMS has indicated that the Federal Marketplace, Healthcare.gov, will provide data for the 33 states that use the FFM; however, it is not clear when any data will be released.

How will states and CMS respond to early data? Some states are taking steps to minimize procedural disenrollments. For example, Idaho paused procedural disenrollments in April because of a technical issue and Iowa is holding open cases to do a “safety check” to ensure that they don’t overlook any documents that have been submitted. How CMS will respond remains uncertain. The agency is working with states to address compliance issues and it does have the authority to require states to pause procedural disenrollments if states do not take corrective action to address compliance issues.

These data raise concerns and signal that outreach to Medicaid enrollees throughout the renewal process could help reduce the rate of procedural disenrollments. However, more months of data may be needed to assess whether there are fundamental problems with how some states are conducting these renewals or whether these high disenrollment rates were temporary and will moderate over time. In the months ahead, it will also be important to continue to examine how variation in policies and implementation of unwinding is affecting disenrollments.