Dec 19, 2023 - Health

Most kids losing Medicaid come from just nine states all led by Republicans

Change in child enrollment in Medicaid and CHIP programs by state
Data: Centers for Medicare and Medicaid Services; Map: Danielle Alberti/Axios

Sixty percent of kids who have lost Medicaid coverage this year came from just nine states, all of which are Republican-led, according to new data from the Biden administration.

Driving the news: And the 10 states refusing the Affordable Care Act's expansion of Medicaid to low-income adults have disenrolled more kids than all of the expansion states combined, the administration also reported.

Why it matters: The data hints at a partisan divide in reviews of Medicaid eligibility after those checks — which were put on hold during the pandemic — resumed this spring.

  • The administration on Monday sent warnings to the nine states with large losses in kids coverage, but federal health officials said they have limited power to require those states to make changes.

Context: At least 2.2 million kids have been removed from Medicaid and its sister program, the Children's Health Insurance Program, during the so-called "unwinding" of pandemic-era coverage protections as of September, according to data from the Centers for Medicare and Medicaid Services.

  • More recent data tracked by outside sources suggest this number is closer to 3 million.
  • Many may have been disenrolled because of a procedural issue and not necessarily because they were no longer eligible. States have been restoring coverage for over 500,000 people, many of them children, who were inappropriately booted from Medicaid because of an error in calculating income.

State of play: Health and Human Services Secretary Xavier Becerra sent letters to Arkansas, Florida, Georgia, Idaho, Montana, New Hampshire, Ohio, South Dakota and Texas on Monday urging them to better protect kids from losing Medicaid.

  • The letters note that HHS "will not hesitate to take action to ensure states' compliance with federal Medicaid requirements," though they don't specify what the department might do.
  • CMS earlier this month warned it will fine states that don't properly report data about who's losing coverage, Modern Healthcare reported.

By the numbers: South Dakota and Idaho recorded the sharpest decreases in Medicaid enrollment among kids between March and September (27%), according to CMS data.

  • Kids' enrollment decreased by more than 10% in most other states receiving warning letters. Enrollment shrank by 9% in Georgia and 6% in Ohio, but those states are among those with the highest number of kids removed from the program.
  • Enrollment also decreased by over 10% in New Mexico, Oklahoma and Utah, but those states did not receive warning letters.

States with the smallest decreases in kids' enrollment were largely blue states. Enrollment actually increased slightly in New York, Oregon, Massachusetts, Rhode Island and Washington, D.C.

  • As of June, more than 20% of children who lost coverage had been re-enrolled in Medicaid or CHIP, federal data shows. It's unclear how many may have found coverage elsewhere, such as through the ACA insurance marketplaces or a parent's employer.

The other side: States contacted by Axios defended the coverage losses and said they had followed federal requirements for the unwinding process

  • "Idaho cares about our families and particularly our children, but Medicaid state and federal eligibility requirements exist for good reason," said AJ McWhorter, a spokesperson for Idaho's health department.
  • McWhorter said Idaho helped move "tens of thousands" of Idahoans, including "many children," from Medicaid to the state's health insurance marketplace after the pandemic coverage requirements ended.
  • A spokesperson for Texas' health department said the state's 12% decrease among kids "is not unexpected," given that they accounted for most of the 50% increase in the state's Medicaid rolls during the pandemic. Texas "is committed to ensuring that those qualified for benefits receive them," said spokesperson Tiffany Young.

Zoom in: States, who run their Medicaid programs with the federal government, have leeway to oversee the unwinding process.

  • The Biden administration said it's approved close to 400 requests from states for administrative flexibilities to make coverage renewals easier.
  • States that take advantage of these temporary changes and rely more on existing state data to automatically re-enroll people on average have disenrolled fewer children, CMS said.
  • CMS on Monday said it's making these flexibilities available through the end of 2024. Some states have asked CMS to make the policies permanently available.

The bottom line: "We cannot force the states to take these up but we are strongly urging states to take these up," federal Medicaid director Dan Tsai told reporters Monday.

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