stock color photo of an African American woman communicating over cell phone while wearing face mask and waiting for medical exam at doctor's office.
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On April 1, state agencies will begin reviewing current enrollees’ eligibility to remain covered by Medicaid and the Children’s Health Insurance Program (CHIP), initiating a nationwide unwinding process. According to estimates from the Department of Health and Human Services, 15 million people may lose coverage once the continuous enrollment provision ends. 

The Families First Coronavirus Response Act originally authorized the continuous coverage plan, a COVID-19 relief measure passed in March 2020 to keep people insured. By November 2022, over 90 million people were enrolled in Medicaid—including nearly 7 million children via CHIP. This is a 28.5% increase from the 71.2 million that were enrolled In February 2020, right before the pandemic hit the U.S. 

It could take some agencies up to 12 months to initiate renewals and an additional two months to complete them. The decision is a result of the Consolidated Appropriations Act, which was passed in Congress’s year-end omnibus spending bill in December and delinks the Medicaid continuous coverage requirement from the COVID-19 public health emergency. 

At the beginning of her first pregnancy, Blount County, Alabama, resident Brittany Kendrick lost her job, as well as her medical insurance. At 14 weeks pregnant, the father of her child died, forcing her to continue the pregnancy alone. The continuous coverage provision allowed her to receive Medicaid in October 2020. 

“If I would not have had the fortune to stay on Medicaid, I would not have made it this far,” she said. “How are you just going to take that away from these people who truly need the help? Not everybody was born with a silver spoon.”

The upcoming unwinding process represents the largest health coverage transition since the first open enrollment period of the Affordable Care Act (ACA) and will send many into the “coverage gap.” Of the 15 million at risk of losing their coverage, 6.8 million may still be eligible but could face numerous administrative barriers to maintaining their coverage, resulting in greater potential loss. Children and people who became eligible through the provision are predicted to experience the largest declines in enrollment.

For the past three years, the continuous coverage plan has been an “essential protection,” said Chris Sanders, communications director at Alabama Arise, an organization advancing public policy to improve the lives of Alabamians marginalized by poverty. 

“It’s peace of mind for people to know that if they need to go to the doctor, they don’t have to ask themselves, ‘Can I afford to go to the doctor? Is this bad enough to go to the emergency room?’” he said. “It’s stability. And ultimately, it’s the humanitarian thing to do to ensure that people are able to get the health care they need, when they need it.”

In the months after giving birth to her daughter, Kendrick struggled with severe postpartum anxiety and depression and felt herself shutting down. Medicaid introduced her to the possibility of therapy. Kendrick said it felt like she could finally breathe, knowing she was able to get the help she needed.

“When I was ready, [Medicaid] was there. And that’s the best feeling in the whole world, just to know that I’m not swept under the rug.”

Today, Kendrick takes care of her 2-year-old daughter and has her own apartment and car.

“Now I just feel like I’m growing. I have all the opportunities, I have all the tools that I need. And now I’m just gonna strive to live a better life—[to] give my daughter a better life.”

Upcoming changes in Medicaid coverage will differ from state to state, depending on whether it’s adopted the ACA’s Medicaid expansion. The Center on Budget and Policy Priorities found BIPOC are more likely to be affected by the unwinding due to structural inequities that make them more likely to be employed in low-paid jobs. These companies often lack employee-sponsored health coverage, leading BIPOC to be overrepresented in Medicaid enrollment. According to a 2022 Medicaid and CHIP Payment and Access Commission brief, over half of the program’s beneficiaries identify as Black, Hispanic, Asian American, or another non-white race or ethnicity. 

Though Sanders and his team knew the unwinding announcement was coming at some point, it was nonetheless disheartening. 

“This announcement was a signal that the problem is about to get worse,” he said. “We’re worried about both people who fall into that coverage gap and people who might remain eligible but could end up nonetheless losing coverage due to a variety of administrative barriers.” 

In the coming months, state agencies are required to submit monthly reports detailing key unwinding metrics, such as the number of renewals completed ex parte (without the beneficiary having to update information), coverage terminations, and call center metrics. 

“On its face, it seems simple enough. But what about people who are not internet savvy, or don’t even have internet?” said Mark Linn, an ACA navigator from Graysville, Alabama. “I have clients who still have landlines. And all these represent barriers for the most marginalized communities.”

Agencies must develop plans to minimize coverage losses to ensure eligible individuals keep their insurance. Things like bolstering agency staffing; allowing for renewals online, over the phone, and on paper; and communicating with enrollees in multiple languages can increase the likelihood that those who need the coverage are able to keep it.

To Linn, technocratic solutions do not sufficiently meet people’s needs. So far, Alabama has worked to communicate with various stakeholders, including nonprofit public health entities and community organizations like his own. They have also hosted webinars and in-person training sessions, and in May 2022, the state initiated the Yellow Postcard Campaign, in which yellow postcards were displayed in pharmacies and provider offices to alert people on how to change their address with the agency. 

“The pandemic showed us how easy it is for people’s access—or lack of access—to health care to mean literally life or death,” Linn said. “The importance [of health care] is individual health, community health, family health—being able to meet these basic needs, which we are more than capable of meeting with just the right amount of political will.” 

Though Kendrick doesn’t have her review until August, she already has to consider other plans. Her work as a forklift operator provides health insurance, but she knows it doesn’t compare to the benefits she receives on Medicaid.

“I got to have Medicaid longer than anybody I know, and it’s helped me to advance,” she said. “I would love to be able to see other women have Medicaid because it’s such a resource. Let all of us get back on track, and I promise this world would be so different.”

Lily Levine (she/her) is a reporter based in Los Angeles and New York. During her time at the University of Chicago, she covered the intersection between health, education, environmental justice, and racial...