The impact of ending the COVID public health emergency

The great “unwinding” of Medicaid enrollment will leave millions without health coverage

The following ominous message is posted on the Medicaid.gov web site:

The expiration of the continuous coverage requirement authorized by the Families First Coronavirus Response Act (FFCRA) presents the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act. … When the continuous requirement expires, states will have up to 12 months to return to normal eligibility and enrollment operations.

With the ending of the COVID-19 federal public health emergency, upwards of 22 million people (including 7.3 million children) are at risk of losing their health coverage by next year. The process of what Washington bureaucrats have euphemistically called the “Medicaid unwinding,” a return to the pre-pandemic normal, began officially on April 1, 2023. Tens of millions of people will be required to submit paperwork to state authorities to determine their eligibility to stay on the government program.

Nursing home residents wait in line to receive a COVID-19 vaccine at Harlem Center for Nursing and Rehabilitation, a nursing home facility, on Friday, Jan. 15, 2021 in Harlem neighborhood of New York. [AP Photo/Yuki Iwamura]

Five states—Arizona, Arkansas, Idaho, New Hampshire and South Dakota—are the first out of the gate to begin terminating Medicaid coverage through a process of mass disenrollment. Come May, an additional 14 states—Florida, Virginia, West Virginia, Pennsylvania, Connecticut, Ohio, Indiana, Iowa, Nebraska, Kansas, Oklahoma, Wyoming, Utah and New Mexico—will follow suit. 

It is unlikely that many of those disenrolled will be able to be reenrolled or find additional insurance coverage, as the states are engaged in the monumental process of “redetermining” who is eligible while facing a massive reduction of staff and resources. Although states must make a “good faith” effort to contact enrollees, or a suspension of the terminations by the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS) indicated that 8.2 million people will most likely no longer qualify, and only 2.7 million may be able to procure coverage under the Affordable Care Act, commonly known as Obamacare.

The Medicaid program, enacted into law under the Social Security Amendments of 1965, is partially funded and primarily managed by the states, which have a wide latitude in determining eligibility and benefits. Medicaid was essentially designed to provide health coverage for the poorest and most disenfranchised, including children, pregnant women, low-income adults, the elderly and people with disabilities. 

Residents of many nursing homes are being evicted because facilities can now stop accepting Medicaid patients because the state-sponsored programs pay so little, making it unprofitable to do so. The cases of Shirley Holtz, 91, who died on Monday, and 15 other residents who were evicted from the Emerald Bay Retirement Community near Green Bay, Wisconsin, demonstrate the situation faced by many Medicaid recipients.

Eric Carlson, an attorney and advocate for the nonprofit Justice in Aging, told the Washington Post, “It’s a good illustration of how Medicaid assisted-living public policy is still in its Wild West phase, with providers doing what they choose in many cases, even though it’s unfair to consumers. You can’t just flip in and out of these relationships and treat the people as incidental damage.” But this is precisely what it happening, and Medicaid and the federal government do not even track these evictions.

It is fair to say that the “unwinding” of Medicaid in fact means that the most vulnerable and destitute of people are being thrown off the proverbial cliff even as the COVID pandemic continues to rampage, despite the declarations by Joe Biden that the “pandemic is over” and that the virus “no longer controls our lives.” Clearly, the president’s vow to “follow the science” of the pandemic when elected was tempered by the more important need of the ruling class to protect corporate profits and the financial markets. According to the mentality of eugenicists like Thomas Friedman and Ezekiel Emanuel, those older Americans who have died from COVID, along with those now being evicted from nursing homes, are an economic drain on society and it is best that they die as soon as possible. 

The entire focus of the Biden administration has been to normalize the death and suffering brought on by the government’s complete disregard of the dangers posed to the public by the coronavirus. Mitigation measures that provided the smallest modicum of protection against the virus have been ended piecemeal, culminating in the current cutoff of emergency Medicaid enrollment.

During his State of the Union address on February 7, Biden offered only the briefest platitudes to the more than 1.3 million Americans killed in the pandemic, stating, “While the virus is not gone, thanks to the resilience of the American people and the ingenuity of medicine, we have broken the COVID grip on us.” He then let slip, “And soon we’ll end the public health emergency.”

Three years ago, on March 18, 2020, when COVID had surpassed just 12,000 official cases and the death toll was still under 200, the Families First Coronavirus Response Act (FFCRA) was signed into law, which provided states with increased Medicaid funding. The law barred states from disenrolling anyone during the COVID pandemic and suspended the requirement for “redetermining” if someone remained eligible to receive the benefits.

Beyond the essential health supplement provisions to treat complications from COVID infections, the FFCRA also provided access to lunch for students and supplemental nutrition assistance program (food stamp) waivers. Additionally, it extended emergency paid sick leave and tax credits for qualified wages, along with family leave to care for those affected. 

Medicaid enrollment reached its peak in 2017, when the number of those eligible had reached 74 million. It then began a slow decline, with 72.7 million on the program in 2019. But by December 2022, total Medicaid/Children’s Health Insurance Program (CHIP) enrollment had grown to 92.3 million, accounting for almost 28 percent of the US population. It is estimated that the number enrolled by March 2023 was 95 million, before the provisions of the FFCRA ended on March 31, 2023.

The numbers reflect both the rise in number of people seeking health coverage and the halting of “churning,” a process by which beneficiaries are disenrolled, either because they were deemed to have earned too much or failed to appropriately complete the renewal process, only to be reenrolled a short time later. The Kaiser Family Foundation added that even “eligible individuals are at risk for losing coverage if they do not receive or understand notices or forms requesting additional information to verify eligibility or do not respond to requests within required timeframes.” 

Health coverage gaps can be catastrophic considering the mass disabling event known as Long COVID, which has no precedent in human history. The hundreds of millions infected or reinfected by COVID face deleterious consequences from these infections, which increase cardiac, respiratory and metabolic disorders. Jennifer Tolbert, an associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation, told the New York Times, “Those people don’t have anywhere else to go. … The consequences would be severe for people with chronic health conditions for whom a week or a month without insurance could be especially risky.” 

Among those killed by COVID, mortality from infection has been five times higher for adults of low socioeconomic status than for those at the other end of the income spectrum (72.2 deaths versus 14.6 deaths per 100,000), according to a study published in the International Journal of Environmental Research and Public HealthLife expectancy in the US has been on a downward trajectory for nearly a decade, impacting the poorest most severely. Most devastating are the deaths among young people. Statistically, one in 25 Americans five years old today will not make it to their 40th birthday, according to John Burn-Murdoch for the Financial Times.

A long-term longitudinal study published in 2011 in the American Journal of Epidemiology, found a disturbing difference in well-being and mortality between the wealthiest and poorest in society. The authors wrote, “The less wealthy may be more subject to poor physical and social environments, which can encourage health-damaging exposures. In addition, the lack of safety net associated with having little or no wealth can cause chronic stress among the poor, which in turn can trigger a series of biologic events, through central nervous system activation of autonomic, neuroendocrine, and immune response resulting in poor health.” And those without health insurance have higher rates or mortality. Long COVID, long-term poverty and social inequality are all manifestations of the same disease—capitalism.

Although President Biden had announced he would formally declare the end of COVID public emergency measures on May 11, 2023, the provisions in the FFCRA that linked enrollment in Medicaid and the pandemic were decoupled by the $1.7 trillion Consolidated Appropriations Act of 2023, ending the Medicaid disenrollment restrictions imposed on states “on or after April 1, 2023.” 

Politicians of both big-business parties are all too eager to provide limitless funds for the war industry but have no qualm in throwing millions of Americans under the bus by discontinuing their only lifeline to obtaining what is exorbitantly expensive health coverage on either the private insurance market or the ACA marketplace. They also face the bureaucratic nightmare of attempting to prove their eligibility for a program to provide them with what is a basic human right—quality, accessible health care.