The COVID-19 pandemic tested the limits of healthcare systems worldwide. In the U.S., enrollment in Medicaid, the public health insurance for low-income adults and children, surged by more than 22 million to reach 94 million people. Much of this surge was thanks to a continuous enrollment provision (enacted under the Families First Coronavirus Response Act), which allowed individuals to maintain their Medicaid coverage without the need for frequent reapplications. Though the federal government provided financial support to states to implement the provision, the influx of enrollees still posed a great challenge for state administrations.
A perfect storm: unwinding Medicaid’s continuous enrollment provision
Both the continuous enrollment provision and the federal funding to support it came to an end in April of 2023. It was then up to each state to redetermine eligibility for constituents enrolled in Medicaid, and to disenroll those who were no longer eligible, as well as those who were still eligible but who failed to complete the renewal process.
Even under normal circumstances, it’s not uncommon for eligible individuals to have gaps in Medicaid coverage or to lose coverage altogether in the course of renewal processes and periodic eligibility checks. Communications are sent through the mail, and notices and forms from the Centers for Medicare & Medicaid Services (CMS) are often lost in the shuffle of paperwork, or enrollees may not understand requests for information to verify eligibility. Fail to respond within the required timeframe, and your coverage is discontinued.
Staffing shortages and outdated systems
In April 2023, administrative staff in each state needed to redetermine Medicaid enrollees’ eligibility, and therefore process large volmes of paper. A need that unfortunately dovetailed with widespread staffing shortages and outdated systems. A recent Kaiser survey found that over half the state Medicaid programs reported personnel shortage among eligibility and call center staff, respectively.
Some states have automated eligibility systems that could more easily and accurately process renewals, reducing the number of renewals staff had to complete manually. Fourteen states reported having mostly manual systems for processing renewals. Most states fell somewhere in the middle when it came to automation, but overall, the level of automation was inversely proportional to the administrative burden on both staff and enrollees during the unwinding period.
The costs of the reenrollment bottleneck
The result of this perfect storm is that more than 10 million people were disenrolled from Medicaid in 2023, with 71% of them disenrolled for procedural reasons and not because they were ineligible. That means two-thirds were disenrolled because they didn’t complete the renewal process, either because the state had outdated contact information or because the enrollee didn’t complete renewal packets within a specific timeframe.
But with the unprecedented volume spike and resulting backlog of reenrollment applications, how much of that 71% occurred because processors were simply overloaded and had no way to scale up reenrollment efforts? Not to mention the role that inaccurate data played in this disaster. Recipients and patient advocates reported that Medicaid officials mailed renewal forms to outdated addresses, miscalculated income levels, and offered insufficient instructions for completing reenrollment.
Overall, attempting to process the cases of tens of millions of people at the same time amidst a staffing shortage not only proved untenable, but also highlighted longstanding weaknesses in the bureaucratic system.
What lies ahead
Disastrous or not, the unwinding is far from over — seventy percent of reenrollment applications have yet to be processed. What this very public train wreck has brought to light is a dire need for scalability, accuracy, and speed in the processing of Medicaid reenrollment applications. Manual processing is failing miserably in all three categories, and the partial automation methods some states have adopted aren’t cutting it.
The clock for Medicaid unwinding is ticking, and the solution may come from an unexpected source. Crowdsourcing offers a way to expand and contract capacity instantaneously without hiring and training staff, temporary or otherwise (a practice that has never been quick, much less instantaneous).
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