The Threat of Medicaid Disenrollment Continues to Grow: At Least 5.3 Million Disenrolled Children and Adults have Behavioral Health Conditions

Ron Manderscheid, PhD

Adjunct Professor,

University of Southern California

&

Johns Hopkins University

On three previous occasions, I have reported on Medicaid eligibility redeterminations (frequently referred to as “unwinding”) now being undertaken for the entire Medicaid population by each of the states. As these redeterminations result in disenrollments, the adverse effects on behavioral health continue to grow. Action is needed now.

States are required to undertake this process by the Congressional Consolidated Appropriations Act of 2022, which mandated the end of continuous Medicaid enrollment. Continuous enrollment was initiated during the COVID-19 medical emergency. It was ended on March 31, 2023. Federal matching funds were phased down by December 31, 2023. States have been undertaking these redeterminations for their Medicaid populations since early in 2023. In the 12 months that redeterminations have been underway, the states have reviewed approximately 70% of their Medicaid populations.

It is very well known that it is exceptionally difficult to enroll people with a mental health or substance use condition in health insurance. It also is true that it is exceptionally difficult to keep such people enrolled. That is why Medicaid redetermination poses a profoundly serious threat to the behavioral health field.

Kaiser Family Foundation (now KFF) estimated at the beginning of the redetermination process that between 8 and 24 million persons would be disenrolled. If one assumes a conservative rate of 25% for behavioral health conditions in this population, we can estimate that between 2 and 6 million persons with mental health or substance use conditions will be disenrolled. This outcome would be tragic for behavioral healthcare.

In the redetermination process, states are required to review all Medicaid participants to determine whether they still are eligible for the program. For a portion of these redeterminations, the states use administrative procedures (ex parte) to determine continued eligibility. Such procedures rely on tax and residential data files to make a redetermination. For the remainder, program participants are required to submit new applications that document continued eligibility.

What is the current status of this process?

To date, national data show that about 21.0 million persons have been disenrolled from Medicaid. Earlier information shows that almost 3 in 4 disenrollments, 70%, were procedural, meaning that the Medicaid recipient did not respond to inquiries for requested information. Further, about 1 in 3 of those with completed renewal applications were also disenrolled.

Earlier data from 20 states show that children constitute about 4 in 10 of those disenrolled. From this, we estimate that, of the 21.0 million people disenrolled, about 8.4 million are children and 12.6 million are adults.

From these facts, we can derive two very important estimates. Viewed very conservatively, we estimate today that at least 2.1 million of the children and at least 3.2 million of the adults disenrolled from Medicaid suffer from one or more behavioral health conditions.

We are particularly concerned about the children and adults with behavioral health conditions who have been disenrolled. Not only are their numbers tragically large and growing, but they also contribute to our current national crisis in mental health and substance use care.

The statistics also suggest strongly that we are not assisting these people to respond to state information requests or to prepare successful applications for renewal. We need to do much better in each of these areas.

KFF has identified 9 factors that improve state Medicaid renewal rates.? These include specific state practices (state takes 12-14 months to complete renewals; state follows up on returned mail; state follows up with enrollees who have not responded); system capacities (process is mostly automated; 50% or more of renewals are done ex parte; state seeks to improve ex parte rates); and eligibility policies (state has expanded Medicaid under the ACA;? state has extended post-partum coverage to 12 months; state has 12 month continuous eligibility for children). It is important that we help to make others aware of the critical role that these elements play in redeterminations that result in renewals, and that we engage in advocacy with states to implement each of them.

Again, I am reminded of the decades-old adage that the true measure of a society is how it treats its children and its disabled members. Let it be said of us that we did all that we could for both groups.

? 2024 R.W.Manderscheid

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