“I’m sorry. You no longer have health insurance.”
Up to 14 million Americans are now at risk of hearing those words at the worst possible moment — in the ER clutching their pained chest or bleeding from an accident, or at their doctor’s office seeking to stabilize a spike in their asthma or diabetes. As one result of ending the U.S. COVID Emergency Declaration, the pandemic continuous enrollment provisions for Medicaid ended on April 1. Medicaid recipients who were protected from disenrollment during the pandemic can be disenrolled now if their eligibility status has changed. Many may not realize that they are required to recertify for eligibility.
It is right to end the COVID Emergency Declaration. It is not right that the American insurance sector fails to attain universal coverage, the standard of all other industrialized democracies. It is not right that insurance in America is so complex that people may not know if they are covered. Puzzlingly, health care finance reform has become a taboo topic in American political discourse. But it is necessary for both pandemic preparedness and health equity.
Medicaid, called Medi-Cal in California, is public health insurance for lower-income and disabled Americans (It should not be confused with Medicare, the public insurance program for the over-65 population). Medicaid has become stop-gap coverage for many Americans left out of employer-sponsored insurance in a patchwork health care finance system. In 1978, about 9% of the U.S. population was covered by Medicaid. By 2021, that had grown to 19%. More than 40% of American births are now covered by Medicaid. Half of adult Medicaid recipients work fulltime, without attaining either employer-sponsored coverage or income adequate to buy insurance.
Medicaid is a means-tested program, open to individuals and families below stipulated income levels. For many lower-income Americans, modest fluctuations in earnings cause continual insurance whiplash as they criss-cross the income cutoffs. The pandemic threatened to exacerbate this so-called Medicaid churn. Employment was destabilized while temporary pandemic assistance programs could put low-wage Medicaid recipients over income-eligibility lines. The churn of people alternately gaining and losing access to Medicaid was recognized as a social threat in pandemic circumstances. Continuous enrollment protection was enacted for any who qualified during the emergency.
The actual number of people on Medicaid during the acute pandemic years who will discover, at the worst moments, that they subsequently lost coverage depends on the quality of transition outreach. Outreach services should notify beneficiaries of recertification processes and assist the newly ineligible to find other coverage.
Requiring continuous enrollment for Medicaid beneficiaries during the length of the declared emergency was one of several federal interventions enacted to thwart the total collapse of American insurance during the pandemic. Defined enrollment periods for Affordable Care Act insurance marketplaces were temporarily ended so applications could be made at any time. The government also shored up employer-sponsored insurance plans. It allowed employer coverage of furloughed employees for open-ended periods during the pandemic economic slowdown. This maintained employer plans’ tax subsidy (they are paid in pre-tax dollars) for indefinitely furloughed as well as continuously employed workers.
In the United States, both making too little money and making too much money can threaten access to health care. So can getting sick. Americans covered by employer-sponsored plans can lose coverage if they become too sick to work fulltime. The COVID pandemic inflated all these paradoxes to the population level. The country was too sick for its mishmash insurance system to provide coverage stability for any quorum of its population. Insurance instability was recognized as both a public health and an economic threat. Hesitation to seek health care could impede treatment, testing, disease surveillance, vaccination and other preventive measures during an epidemic.
As we exit the emergency declaration (though COVID is far from over), public discussion turns to lessons learned for future pandemic preparedness. One lesson is clear. All Americans need stable access to health insurance in a comprehensible system. Health care finance reform is necessary for pandemic planning — as well as for justice.
Ann Mongoven is a health care ethicist living in San Jose.
Source: www.mercurynews.com