VISIT STATE HEALTH COMPARE
Publication
by Unknown
State Estimates of the Low-Income Uninsured Not Eligible for the ACA Medicaid Expansion
The Patient Protection and Affordable Care Act (ACA) will expand access to affordable health insurance for millions of Americans. In states that choose to implement the Medicaid expansion for low-income adults, Medicaid will provide an important new pathway to coverage. Yet, even in states that choose to expand Medicaid a significant proportion of the low-income nonelderly adult population will be excluded from the Medicaid expansion due to their immigration status. Legal permanent residents, in most circumstances, are ineligible for Medicaid benefits for the first five years during which they reside legally in the U.S. and unauthorized immigrants are excluded from Medicaid coverage. SHADAC Issue Brief #35 provides the first state-specific estimates of the number of uninsured low-income adults that will potentially be excluded from the Medicaid expansion because of their immigration status.
Blog & News
State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement (SHVS Expert Perspective Cross-Post)
May 15, 2023:
The following content is cross-posted from State Health & Value Strategies.
Authors: Elizabeth Lukanen, Emily Zylla, SHADAC
This expert perspective (EP) will be updated by SHADAC experts as additional dashboards/reports go live. Please visit the State Health & Values Strategies webpage for the most recent version of this EP.
Original publication date: March 16, 2023. Updated May 15, 2023.
The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act, with significant health equity implications. As states restart eligibility redeterminations, millions of Medicaid enrollees will be at risk of losing their coverage with some portion exiting because they are no longer eligible, some losing coverage due to administrative challenges despite continued eligibility, and some transitioning to another source of coverage. As part of this process, the Centers for Medicare & Medicaid Services (CMS) will require states to closely track and monitor the impacts of the resumption of eligibility redeterminations and disenrollments, and plans to make some of those data public. CMS’ commitment to transparency is mirrored by calls from advocates and researchers eager to see how progress is being made as people enrolled in Medicaid have their eligibility redetermined.
Given the intense focus on coverage transitions during the unwinding, some states have initiated plans to publish a data dashboard to monitor progress. Data dashboards are useful for publishing dynamic data that is in high demand. They allow states to make proactive decisions about what data to release and on what schedule and then organize that data in an easy-to-digest visual format that facilitates the interpretation of key trends and patterns at a glance.
States Publicly Posting Unwinding Data
To date, the District of Columbia and 11 states have published unwinding data in a visual dashboard format (this does not include states with pre-existing enrollment dashboards that don’t specifically identify unwinding cohorts). The majority of states are releasing data online in an interactive format; but two states, Arizona and Washington, have released their data as a static pdf). Three states—Arkansas, Indiana, and Iowa (which is not shown on the map above because Iowa also released a dashboard)—have released their Monthly Unwinding Data reports that states are required to submit to CMS. SHADAC will update this expert perspective as additional dashboards and reports go live.
Variation in States’ Reporting of Indicators
There is a wide variation in the required indicators that states are reporting on their data dashboards (Table 1). It’s important to note, however, that states are beginning to disenroll people from Medicaid in different months; for example, five states began disenrollments in April and another 14 states are expected to begin disenrollments in May. Several states with live dashboards, such as Pennsylvania, have not yet begun disenrollments and therefore have not populated their outcome data (e.g., the number of terminations, electronic transfers, etc.).
Table 1. Unwinding Indicators Reported by States
Even fewer states are reporting disaggregated data on their dashboards (Table 2). The most common breakdown states are providing is by program type. Although CMS only asks states to report data by modified adjusted gross income (MAGI) and non-disability applications, versus disability applications, additional data breakdowns by age, race, ethnicity, and geography can elucidate important trends about the disproportionate impact of unwinding on groups that have been economically or socially marginalized.
Table 2. Disaggregated Unwinding Data Reported by States
State Unwinding Dashboards - Select Data Highlights
Arizona Health Care Cost Containment System – Eligibility Dashboard
Unwinding data is presented as a static document (pdf). Provides the number of renewals in process, closed, and approved for regular Medicaid members and “COVID override” members (individuals who did not complete a renewal or failed to supply needed documentation during the public health emergency, or those who were found to be factually ineligible during that time). Also provides counts of the number of COVID override individuals enrolled by health plan and detailed race and ethnicity information for individuals enrolled, renewed, and terminated.
Screenshot: 5/10/2023
Minnesota Department of Human Services – Renewal Dashboard
Provides the ability to disaggregate data in various ways such as by county, social vulnerability quartile and member race/ethnicity.
Screenshot: 3/13/2023
Ohio Department of Medicaid – Eligibility Renewal Dashboard
Provides overviews of pending renewals, ex parte renewals, non-response closures, and renewals completed by geographic level (county) and by different metrics (e.g., counts by county, rates per 1,000 active Medicaid members, and by caseworker staff load).
Screenshot: 5/9/2023
Oregon Department of Human Services – Medical Redeterminations Dashboard
Provides statistics showing the number of renewals due each month as well as the number not started, initiated, and completed. Oregon also publishes call center data (shown below). Oregon’s House Bill 4035 requires that the Oregon Health Authority and Oregon Department of Human Services make information about the Medical Assistance program redetermination process available on a publicly accessible website. The state notes that additional demographic and other program data will be published in the future.
Screenshot: 5/3/2023
Utah Department of Health & Human Services – Unwinding Eligibility Data Dashboard
Provides detail on redetermination progress (e.g., average days to decision, fair hearing requests, reviews for non-Medical program) and outcomes (e.g., transfers to the Marketplace, transitions from Medicaid to CHIP).
Screenshot: 3/13/2023
Washington State Health Care Authority – Continuous Enrollment Unwind Data
Unwinding data is presented as a static document (pdf). It appears this data will be updated monthly. Data are focused on the timing and characteristics of forthcoming renewals, including detail by month, managed care organization, and demographics (e.g., age, race, language, and geography).
Screenshot: 5/3/2023
Publication
by Unknown
Opportunities to Learn More About Serving Justice-Involved Individuals Through 1115 Demonstration Evaluations
Medicaid is a vital source of coverage for the almost four million justice-involved individuals living in the community – individuals who are disproportionately poor and people of color. Upon release from prison or jail, many of these individuals face significant obstacles navigating and accessing medical and behavioral health care services. Therefore, many state Medicaid programs, as well as the federal government, are looking at ways to improve continuity of coverage, provide seamless transitions back to the community, and reduce disparities in health care access. A major obstacle states face in trying to improve access to care for justice-involved individuals is the Medicaid inmate exclusion policy – a provision in the Social Security Act Amendments of 1965 that prohibits use of federal Medicaid funds for most health care services during incarceration. One way a growing number of states are trying to support reentry for justice-involved individuals is by providing Medicaid services prior to release from prison or jail through a Section 1115 demonstration waiver. Under Section 1115 of the Social Security Act, states can apply for a waiver to test new policies in their Medicaid program that federal rules typically do not allow.
In April 2023, the Centers for Medicare & Medicaid Services (CMS) issued new guidance outlining opportunities for states to design 1115 demonstration projects to improve care transitions for incarcerated individuals. Before the CMS guidance was released in January 2023, California became the first state to receive 1115 demonstration authority approval to waive the inmate exclusion and provide some Medicaid services in the 90 days pre-release. As of February 2023, an additional fourteen states have pending reentry demonstration proposals before CMS.
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This new issue brief from SHADAC researchers, funded by the California Health Care Foundation (CHCF), identifies the unique opportunities states should consider when designing evaluation plans specific to their justice-involved populations, provides an overview of justice-involved 1115 demonstration initiatives, and summarizes what is known from existing evaluations of these activities. The brief also identifies a set of opportunities to design robust and equity-focused 1115 demonstration evaluation plans specific to justice-involved populations. Given the complex dynamics, unique obstacles, and varied experiences justice-involved individuals face, a new, more equity-focused evaluation approach is needed. |
Key recommendations for designing a robust and accountable evaluation of justice-involved initiatives.
1. Center the voices of people with lived experience in the evaluation approach
2. Collect robust monitoring data in order to build evidence for a topic where existing knowledge is limited
3. Consider additional meaningful outcome measures outside typical health outcomes
4. Seek to understand the unique experiences of different populations in the data analysis plan in order to address equity
5. Prioritize cross-sector data linkage activities and start planning early
To complete this work, SHADAC researchers reviewed states’ 1115 waiver applications, related CMS guidance and public waiver documentation, relevant grey and peer-reviewed literature, and conducted interviews with 11 key informants with expertise in state Medicaid, federal policy, justice-involved health care, evaluation, and lived experience.
Related Reading:
Targeting Justice-Involved Populations through 1115 Medicaid Waiver Initiatives: State Implementation Experiences (SHADAC)
From Corrections to Community: Reentry Health Care (CHCF Project)
This work is supported by:
Publication
by Unknown
What the Growing Medicaid Undercount Means for Data Users and Policymakers
SHADAC hosted a one-hour webinar on Wednesday, April 5th to discuss the rising Medicaid undercount. With many states and stakeholders eager to understand the topic further, this webinar provided an overview of issues related to the Medicaid undercount along with relevant policy implications. View a recording of this webinar below!
Download the slidedeck from this webinar here.
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The extent to which, how, and why 2021 coverage data underestimated Medicaid coverage and/or overestimated uninsurance
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The data and methodology used to calculate the undercount
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How policy and advocacy may be impacted by the growing Medicaid undercount
The panel also answered questions from the audience following their presentation. Due to time constraints, the panelists were unable to answer all audience-submitted questions live. Please click here to view those additional Q&A.
Speakers
Lynn Blewett
Director @SHADAC
Dr. Lynn Blewett is the Founding Director of SHADAC, as well as a Professor in the Division of Health Policy and Management at the University of Minnesota, School of Public Health, where she teaches graduate courses on the U.S. health care system and international health systems. Her health policy experience includes legislative work for the U.S. Senate and state policy work as Director of the Health Economics Program for the Minnesota Department of Health.
Benjamin Sommers
Dr. Benjamin Sommers is a health economist, primary care physician, and professor. Dr. Sommers currently serves as a Senior Counselor to the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services, where he was previously the Deputy Assistant Secretary for Health Policy. He is also the Huntley Quelch Professor of Health Care Economics at the Harvard School of Public Health. His research interests include health insurance markets, Medicaid, health disparities, and the health care safety net.
Robert Hest
Robert Hest is a Senior Research Fellow at SHADAC. Mr. Hest provides expertise in survey data, quantitative data analysis, data visualization, and health coverage policy. Mr. Hest also manages SHADAC’s State Health Compare website, coordinating data processing, quality assurance, dissemination, and documentation of data. In addition, Mr. Hest provides technical assistance to states and other organizations on topics related to health coverage, cost, and access.
Genevieve Kenney
Co-Director and Senior Fellow @Urban Institute
Genevieve M. Kenney is co-Director and a Senior Fellow in the Health Policy Center at the Urban Institute. Dr. Kenney is an expert on Medicaid, CHIP, and health outcomes for low-income adults, children, and families. She has also played a lead role in a number of Medicaid and CHIP evaluations, including multiple congressionally mandated evaluations of CHIP, and has conducted state-level evaluations of the implementation of managed care and other service delivery reform initiatives and policy changes in Medicaid and CHIP.
Joan Alker
Executive Director @Georgetown University Center for Children and Families
Joan Alker is the Executive Director and Co-Founder of the Georgetown University Center for Children and Families and a Research Professor at the McCourt School of Public Policy at Georgetown University. She is a nationally recognized expert on Medicaid and the Children’s Health Insurance Program (CHIP) and is the lead author of CCF’s annual report on children’s health coverage trends.
Blog & News
MPP , Senior Research Fellow
Recent Publication Round-Up: The 2021 Medicaid Undercount
February 1, 2023:Research has consistently shown that surveys that measure health insurance coverage underestimate the number of people enrolled in Medicaid; this is known as the “Medicaid undercount.” SHADAC researchers have long monitored and investigated the magnitude, causes, and effects of the Medicaid undercount across surveys such as the American Community Survey (ACS) and Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and its prevalence across states and populations.
Two recent SHADAC publications investigate the large increase in the size of the undercount in the 2021 ACS, providing new information and guidance for data users:
The first, “Medicaid Undercount Doubles, Likely Tied to Enrollee Misreporting of Coverage,” describes the large increase in the undercount in the ACS, using longitudinal data from the CPS ASEC to analyze the extent to which the increase in the undercount may be tied to an increase in Medicaid enrollees’ misreporting of coverage due to the pandemic-era Medicaid continuous coverage requirement. |
The second, “Tracking the Medicaid Undercount in the 2021 ACS Coverage Data,” presents state variation in the 2021 ACS’ undercount, how analytic choices such as health insurance coverage hierarchies and misaligned analytic universes (i.e., all persons vs. noninstitutionalized persons) can affect the apparent size of the undercount, and best practices for using 2021 ACS coverage data in light of the increased undercount. |
SHADAC continues to monitor and investigate the Medicaid undercount in surveys of health insurance coverage. The undercount will remain an active area of interest as survey estimates of 2022 health insurance coverage are released later this year and as the “unwinding” of the Medicaid continuous coverage requirement begins this spring.
