End of the pandemic could usher in spike of uninsured

The big picture: The massive drop in the insured rate that was feared early on in the pandemic never materialized, thanks to Medicaid and enhanced ACA subsidies.

• Congress in 2020 included measures in pandemic relief legislation that increased the share of federal Medicaid spending if states offered continuous coverage to enrollees, suspending the program's usual churn.
• A year later, Democrats increased the value of Affordable Care Act subsidies and expanded who was eligible for premium assistance.
• Both programs then served as safety nets for people who lost their employer-sponsored coverage during the pandemic or would have otherwise been unable to afford insurance. But the extra allowances are due to sunset with the end of the public health emergency or at the end of the year.

What they're saying: "If continuous coverage in Medicaid ends and the extra ACA premium assistance isn’t extended, we could see one of the biggest jumps in the number of people uninsured ever," said Kaiser Family Foundation's Larry Levitt.

State of play: The Medicaid changes are tied to the formal Public Health Emergency, which is currently scheduled to end April 15. The prevailing assumption is that it'll likely receive one more extension and then expire sometime this summer.

• States will then determine whether their Medicaid enrollees are still eligible for coverage — a huge undertaking that could result in millions of Americans being removed from the program.
• “Pretty clearly, this is going to be one of the biggest inflection points for health coverage that we've seen in a very long time — in a decade at least, and it's probably going to mean the largest reduction in Medicaid coverage in memory," said Matt Salo, executive director of the National Association of Medicaid Directors.
• Salo estimated that some 10–15% of the Medicaid population -- potentially more than 12 million people — will fall off the program rolls.

Where it stands: Although extending the enhanced ACA subsidies is a key part of Democrats' health care agenda, it's unclear whether their stalled domestic policy legislation can be revived.

• Under current law, the enhanced subsidies expire at the end of the calendar year.

• The stalled legislation also would ease the expiring Public Health Emergency's impact on Medicaid.

Between the lines: Even if millions of Medicaid enrollees are removed from the program, that doesn't mean they'll all become uninsured.

• Many who've returned to work can likely get insurance through their employer. Others could get coverage through the ACA marketplace. But that becomes less likely without the extra financial assistance that's currently being offered.
• "While the majority of the people who would be leaving Medicaid would likely be eligible for employer coverage, a substantial minority would likely turn to the marketplace. And marketplace coverage will look a lot more attractive if the expanded subsidies continue," said Matt Fiedler of the USC-Brookings Schaeffer Initiative for Health Policy.

By the numbers: ACA marketplace enrollment hit a record high this year, but it could come crashing down next year.

• Around 1.7 million people nationally could drop their insurance, according to a recent Covered California analysis, and millions more would see significantly higher premiums.
• As of September, around 14 million more people were insured through Medicaid than at the start of the pandemic.

What we're watching: States will have a huge role in ensuring eligible people remain enrolled in Medicaid and those who aren't eligible are connected to other forms of coverage, including ACA plans.

• "It's going to involve really reaching out to the community more so than states have had to do in the past," Salo said. "There's very clearly going to have to be a lot more handoffs [and] a lot of human touches."