In the first few months of the COVID-19 pandemic, before vaccines and therapies were available, hospital emergency departments were suddenly empty as people avoided them for fear of exposure to the virus.
“We were concerned patients weren’t coming in when they should be,” recalls Jamie Shoemaker, MD, a partner with Elite Emergency Physicians, Inc., based in Indiana, and a member of the American College of Emergency Physicians (ACEP) board.
It wasn’t long before emergency departments were filling up again, though — this time with people who were sicker, likely from waiting to seek treatment, Shoemaker says.
Emergency physicians and their fellow frontline clinicians have experienced a difficult few years, from the financial impacts of lower volumes early in the pandemic, to the burnout associated with the high volumes of the pandemic peaks, to the current challenges posed by nursing shortages leading to patients staying in the emergency department longer before hospital admission.
They are about to face yet another challenge. Millions of people nationwide could lose Medicaid coverage over the next few months with the end of the federal public health emergency, which becomes official on May 11. Those newly uninsured people could wind up seeking uncompensated care in the emergency department because they no longer have anywhere else to go.
“We’re the safety net for medicine,” Shoemaker says. “And it’s frayed.”
A silver lining to the pandemic
The COVID-19 pandemic wreaked havoc on the nation’s health care system, but one silver lining was the guarantee of continuous coverage for people insured by Medicaid and the Children’s Health Insurance Program (CHIP), two state and federally funded insurance programs for people with lower incomes.
During the pandemic, the federal government provided extra funding to states under the Medicaid Continuous Enrollment Provision to help them enroll eligible people in Medicaid and CHIP and allow those patients to keep their insurance without having to reenroll every year.
Over the past three years, 21 million people enrolled in Medicaid, a 29% increase over pre-pandemic levels, according to the Kaiser Family Foundation. In early 2022, the United States reported a historically low uninsured rate of 8%.
“When people have periods of uninsurance they experience higher levels of medical debt, providers experience higher levels of uncompensated care, [and people have] less access to health care they need.”
Joan Alker, Georgetown University McCourt School of Public Policy
Now, as the federal government winds down its pandemic response with an end to the public health emergency, advocates for health care access worry that as many as 17 million people could lose coverage as Medicaid unwinding takes place. While some will go through the process to be reenrolled, and others who are no longer eligible will be able to get a subsidized plan via the Affordable Care Act (ACA) Marketplace, an estimated 6.8 million could fall through the bureaucratic cracks, leaving them uninsured.
“When people have periods of uninsurance they experience higher levels of medical debt, providers experience higher levels of uncompensated care, [and people have] less access to health care they need,” says Joan Alker, executive director of the Center for Children and Families and a research professor at the Georgetown University McCourt School of Public Policy.
Non-urgent medical issues are better addressed by primary care or specialty care providers who can establish ongoing treatment in a more continuous and cost-effective way.
But people without insurance coverage often end up coming into the emergency department, either for issues generally addressed by primary care providers or because untreated illnesses or injuries become exacerbated, requiring urgent care, Shoemaker explains.
A piecemeal approach
The Medicaid unwinding landscape will look different across the country. Each state is responsible for managing the changes to its Medicaid program though they will be assisted by a phase down of the additional federal funding which expires in December 2023.
Five states started disenrolling people in April, either for procedural reasons or because they were no longer deemed eligible for Medicaid. Arizona, for example, disenrolled 35,000 enrollees in the first week of April, the earliest the federal protections allowed disenrollment. In May, another 14 states plan to begin disenrolling people.
Disenrollment can happen for a number of reasons, including that the person is earning above the income limit or is now able to obtain insurance through an employer. In these cases, ideally, the person would be seamlessly transitioned to another source of health insurance coverage, whether through a subsidized plan on the ACA Marketplace or through an employer plan, Alker says.
However, some people may lose coverage due to “churn,” she adds, for example, an outdated address for renewal paperwork, a language barrier that prevents someone from completing renewals, or another bureaucratic gap. This could include millions of children; approximately half of all children in the United States are insured through Medicaid or CHIP.
“This is a huge undertaking for Medicaid programs,” Alker says. “There are lots of reasons why this process can go wrong even during normal times.”
Additionally, in the 12 states that did not expand Medicaid coverage (including two states that recently voted to expand Medicaid, but have not yet implemented it), an estimated 383,000 individuals will fall into a category where they have an income too high to qualify for Medicaid but too low to receive ACA Marketplace tax credits, according to a report by the U.S. Department of Health and Human Services.
“We’re going from basically universal coverage … [back to] our normal system [which] is fractured and fragmented and unequal,” says Georges Benjamin, MD, executive director of the American Public Health Association. “The [emergency federal funding] kept a lot of hospitals afloat [and] provided needed dollars for staffing, infrastructure, and therapeutics. I think it makes a strong argument for government intervention in our health care system.”
A frayed safety net
Medicaid unwinding comes at a time when, rather than experiencing relief from the diminishing impact of COVID-19, many emergency departments and emergency physicians are struggling.
“We are now the specialty with the highest number of doctors reporting mental health concerns as well as a rise in suicide,” says Adam Krushinskie, reimbursement manager at the ACEP. “Hospitals don’t have enough beds and enough nurses for every patient who comes through the door, so emergency physicians have borne the brunt of having to triage and manage all of these patients. Many times, we have patients in hallways, in corridors, even areas outside of the [emergency department] in extreme cases.”
In some regions of the country, even a small uptick in uninsured patients seeking care in the emergency department could have an impact on a hospital’s ability to provide timely care.
“[We’ll have] longer wait times, increased boarding, some patients in the waiting room may leave without being seen,” Shoemaker says. “It’s a house of cards.”
Though Shoemaker worries about the impact Medicaid unwinding could have, he hopes that, if done well, the process can prevent as many people as possible from becoming uninsured. In his home state of Indiana, state legislators are talking about using a budget surplus for additional Medicaid funding.
“Hospitals don’t have enough beds and enough nurses for every patient who comes through the door, so emergency physicians have borne the brunt of having to triage and manage all of these patients. Many times, we have patients in hallways, in corridors, even areas outside of the [emergency department] in extreme cases.”
Adam Krushinskie, American College of Emergency Physicians
North Carolina’s state legislature recently voted to expand Medicaid coverage to make an estimated additional 600,000 people eligible.
Abhi Mehrotra, MD, a professor and emergency physician in the Department of Emergency Medicine at University of North Carolina School of Medicine, says that the 14 emergency departments he oversees are currently overcrowded and understaffed, with about 30% of their patients being uninsured. With both the end of continuous enrollment and the expansion of Medicaid happening in his state, Mehrotra anticipates a lot of fluctuations in patient coverage status and emergency department use.
“We estimate [Medicaid expansion] will increase coverage for more patients,” he says. “[But] coverage does not necessarily mean access to care. We don’t have a magic [new] number of primary care physicians.”
Some states are taking measures to address issues of coverage and access. Oregon has adopted a new waiver that allows children to have continuous coverage from birth to age 6 and Minnesota has developed a detailed dashboard to track the unwinding process which allows advocates to monitor potential issues.
“Transparency, like these data dashboards, helps stakeholders and other states see what a state is doing,” says Allexa Gardner, a senior research associate for the Center for Children and Families at Georgetown University McCourt School of Public Policy who has helped lead a project to publish a map tracking each state’s unwinding process. She and her colleagues will continue to track various metrics across states over time so they can monitor the process and help identify problems, such as exacerbated racial disparities or a high number of children losing coverage.
“These metrics can provide warning signs that something’s going wrong so state advocates can reach out to the state to figure out where corrective action may be needed,” Gardner says.
Many state Medicaid agencies are making efforts to communicate with people about the unwinding process and how they can make sure they don’t lose insurance coverage.
And while emergency departments are usually forbidden from posting any signage that could imply insurance is required for treatment, the Centers for Medicare and Medicaid Services (CMS) has approved wording for signs and flyers to be displayed and distributed in emergency departments to inform patients about the changes in Medicaid and what they may need to do. There is also a CMS communications toolkit to help physicians and other staff keep their patients informed about the unwinding process and what might be required of patients to maintain coverage.
“This is going to take a village and providers will certainly be on the frontlines when coverage losses happen,” Alker says.
While Shoemaker is advocating for policies that help all patients have access to insurance coverage, he accepts that emergency departments will continue to serve as a safety net.
“I never want a patient to second guess coming to the [emergency department]” he says. “We take care of everybody regardless of their ability to pay.”