Medicaid Continuous Coverage Unwinding: New Era, New Opportunities

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At the end of this month, a pandemic-era guarantee of stable health insurance for low-income families will come to an end. The Medicaid continuous coverage unwinding will trigger the most significant coverage event since the Affordable Care Act (ACA) became law in 2010. Impending renewals put the coverage of millions of Medicaid-eligible individuals at risk.  

Although the volume of application renewals will present challenges in all states, families are especially susceptible to the impacts of this upcoming change in states that have not expanded Medicaid. As a research center focused on infants and toddlers, we are particularly concerned that new parents and childless adults who may become pregnant may lose coverage during the unwinding. This period of change offers a fresh opportunity for states to consider policy decisions protecting all families’ health care coverage and supporting the prenatal-to-3 (PN-3) period. 

How did we get here? 

In most states, pregnant people can enroll in Medicaid more easily (at higher incomes) than other adults. Typically, however, pregnancy coverage only lasts for 60 days postpartum. At that point, the person must switch to traditional Medicaid or use a subsidy to purchase health coverage on the Marketplace. 

When COVID-19 hit, the ensuing public health crisis and economic downturn ushered in a new era of policies designed to protect families’ access to health care coverage. With the Families First Coronavirus Response Act in March of 2020, Congress prohibited states from disenrolling individuals from Medicaid during the public health emergency. For more than 3 years, this continuous coverage provision has allowed millions of people to maintain coverage without interruptions.  

The recently passed 2023 Consolidated Appropriations Act (CAA) delinks the Medicaid continuous coverage requirement from the COVID-19 public health emergency, ending the continuous coverage provision March 31, 2023. Beginning April 1, for the first time in 3 years, states can terminate Medicaid enrollment for individuals who are no longer eligible because of their income.  

How high are the stakes? 

Experts have been warning that up to 15 million individuals risk losing health insurance in this process. Many of these individuals are still eligible based on their income levels, but they will lose coverage because of procedural reasons and red tape.   

People in the 10 states that have not expanded Medicaid will be most impacted by the unwinding, because they lack a path for affordable health insurance. In non-expansion states, Medicaid-enrolled children who turned 19 during the last 3 years will lose coverage if they are childless—resulting in more adults of childbearing age without insurance. Those with low incomes may struggle to access family planning services, preventative care before conception, and prenatal care in the earliest stages of pregnancy. And new parents who are enrolled often lose coverage after the postpartum period because their incomes are too high for traditional Medicaid, but not high enough (100% of the federal poverty level, or FPL) to receive subsidies on the Marketplace. In the next section, we discuss evidence for the importance of extending postpartum coverage. 

Expanding income eligibility for health insurance, specifically implementing the Medicaid Expansion under the ACA, is one of our Center’s five Roadmap policies. Medicaid expansion increases families’ access to needed care and services, reduces financial burdens associated with health care costs, leads to fewer infant and maternal deaths among Hispanic and Black families, and decreases reports of neglect.  

Why does adults’ coverage matter for the PN-3 period? 

Coverage for both childless adults (prior to conception) and new parents is important to ensure all children thrive from the start. Evidence shows expanded income eligibility for health insurance for childless adults may improve birth outcomes. Family planning services and pre-conception preventative care support healthy birth outcomes by improving parents’ health and preparing them for pregnancy and birth.  

Once a person becomes pregnant, early and regular prenatal care allows providers to assess and treat health conditions prior to birth. This care leads to safer and healthier pregnancies and births, as well as lower rates of birth complications, maternal and infant mortality, low birthweight, and preterm birth.  

After the birth of a new child, stable postpartum coverage improves interpregnancy care and helps birthing people ensure healthy pregnancy spacing, which influences outcomes such as prematurity and birth weight. Research shows 84% of pregnancy-related deaths are preventable, and stable coverage provided through postpartum Medicaid can increase access to screenings and services to diagnose and treat conditions that occur disproportionately later in the postpartum period. 

Note: For an in-depth analysis of the impacts on children’s coverage, see the Georgetown Center for Children and Family’s recent report

Who will be affected by the unwinding? 

Both childless adults of reproductive age and new parents may lose coverage. This is especially true in states that have not expanded Medicaid. For example, in Texas, where postpartum coverage ends 60 days following birth, birthing people who were previously covered under pregnancy Medicaid are ineligible for coverage if their family income is above 16% of the FPL. This means, in a three-person household making $331 a month, parents will lose coverage when their baby turns 2 months old. 

For many of these childless adults and new parents, the past 3 years of continuous coverage is all they know. Many adults of childbearing age only aged out of children’s Medicaid in the past 3 years. And many birthing people who received pregnancy Medicaid during the pandemic have never been through a renewal process.  

Even if these individuals qualify for coverage based on income, they could lose coverage for procedural reasons or a lack of awareness of the unwinding. Most adults do not know about this upcoming change. An analysis published last month by the Robert Wood Johnson Foundation shows more than 60% are not aware their eligibility for Medicaid could be in danger. 

What can states do? 

To reap all the benefits that families need to thrive, states should consider fully expanding Medicaid under the ACA. Just yesterday, North Carolina Governor Roy Cooper signed HB 76 into law to expand Medicaid in the state. As the Medicaid continuous coverage provision unwinds, state and county officials hope enacting Medicaid expansion will protect coverage for many North Carolinians. 

Another option is to extend postpartum coverage. The CAA made permanent a previously temporary state option to extend Medicaid coverage beyond the 60-day postpartum timeline to one year. Just this year, legislation to execute that option has gained unprecedented support in non-expansion states that previously rejected the policy: 

  • Wyoming’s governor signed the 12-month postpartum extension into law this month.  
  • Mississippi’s governor signed a postpartum extension bill into law this month, after years of House leadership refusing to consider similar proposals.  
  • Texas legislators are expressing cautious optimism around a bill to extend postpartum coverage to 12 months.  

Although the emerging trend of states adopting postpartum extension is encouraging, it is only one incremental step in providing stable health care coverage to boost PN-3 outcomes. 

To see the full range of actions states can take to foster the nurturing environments infants and toddlers need, visit the 2022 Roadmap. The PN-3 Policy Impact Center will continue to monitor the policy landscape during this time of great change and great opportunities in health care coverage for families. Be sure to follow us on social media and sign up for our newsletter to stay up-to-date as the situation unfolds. 

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