Congress can help prevent health coverage disruptions and lock in recent gains

The uninsured rate is at a record low, according to the latest census data. One major reason: the temporary ban on ending Medicaid coverage for most enrollees during the federally declared public health emergency (PHE). But that “continuous coverage” requirement will drop when PHE ends, probably next year. As Congress begins work on legislation at the end of the year, policies that protect and strengthen health coverage, especially for low-income people, must be a top priority.

Ensuring continued Medicaid coverage has helped people, including millions of children, stay insured despite the economic and social disruption caused by the COVID-19 pandemic. Requiring continuous coverage helped prevent withdrawals and exclusions from Medicaid coverage, which often happen when people’s incomes fluctuate or if they cannot meet the documentation requirements that are often part of eligibility checks. Attrition hurts Medicaid enrollees, cutting off access to drugs and other needed care, and is an administrative burden for states, providers and health plans. Research also shows that paperwork requirements and other administrative burdens often mean people lose coverage and don’t re-enroll in Medicaid or other programs for which they may be eligible.

Congress should learn important lessons from the past two years and adopt policies to help minimize coverage interruptions when the continuous coverage requirement ends. Doing so now can help stem widely anticipated coverage losses and ensure broad coverage for the future, giving more people access to life-saving health care and financial protection. Enacting policies to help maintain record low uninsured rates is also key to advancing health equity; the uninsured rate fell to a record low among blacks in 2021. Policymakers must prioritize approaches to sustaining these gains.

Congress should include the following policies in year-end legislation to minimize coverage interruptions and loss of coverage and help lock in coverage gains:

  • Extension of postnatal coverage up to 12 months. Recognizing the importance of continued coverage after birth, America’s Rescue Plan allowed states to extend postpartum coverage for 12 months after birth, rather than the 60 days otherwise required by law. To date, 33 states and the District of Columbia have adopted the option or announced plans to do so. But the American Rescue Plan coverage option is only available until March 2027.

    To help reduce the maternal and infant mortality crisis, Congress should permanently increase mandatory pregnancy coverage from 60 days to one year after birth. This could eliminate the risk of lapses in coverage in all states, but is especially important in the 12 states that have not expanded Medicaid, because very low-income postpartum people often lose Medicaid coverage 60 days after birth in states without expansion. Requiring a full year of postpartum coverage in all states can help address equity in maternal health; Postpartum coverage is especially important for blacks, who are slightly more likely to experience life-threatening pregnancy complications in the late postpartum period (between six weeks and one year postpartum) than whites.

  • Requirement of continuous eligibility for children. Even before the requirement for continuous PHE coverage, states had the option of providing children with “continuous eligibility,” meaning that children remained eligible for Medicaid (or the Children’s Health Insurance Program, or CHIP) for a 12-month period regardless of changes in their family income. As of January 2022, about 32 states (including the District of Columbia) provided 12 months of continuous Medicaid and/or CHIP eligibility for children under 19.

    Ensuring continuity of coverage for children increases the share of children accessing preventive care and reduces the shares experiencing coverage gaps and unmet medical needs, studies show. It also reduces the administrative burden and administrative costs for states. The evidence is strong, and Congress should require all states to implement continuous eligibility for children. This would help improve health equity by promoting continuity of coverage for children from low-income families who experience disproportionate levels of health care disparities.

  • Introduce at least a state plan option for continuous eligibility for adults. Continuous 12-month eligibility may help prevent coverage losses among adults as well, and could further help children because enrollment of adults is positively related to enrollment of children. At a minimum, Congress should allow—if not require—states to provide 12 months of continuous entitlement to adults without seeking federal approval through a Section 1115 demonstration or waiver. Since earlier this year, four states have used Section 1115 demonstration projects to allow continuous eligibility for adults. Last week, two more states—Massachusetts and Oregon—received approval to provide continuous eligibility to some or all adults (along with an innovative continuous eligibility to children up to age 5 in Oregon). Even if Congress does not require it, more states will adopt this important policy if Congress gives states the option of a permanent state plan to adopt continuous coverage for adults.
  • Provide additional funding for Puerto Rico and other US territories. Without action from Congress this year, the more than 1 million Puerto Ricans who rely on Medicaid for their health care could face deep cuts to eligibility, benefits and already low provider payments. As in the states, the uninsured rate in Puerto Rico fell between 2019 and 2021 from 7.8 percent to 5.7 percent. At least some of this decline is due to the continuous coverage requirement and increased Medicaid funding provided over the past few years. Given the territories’ unique funding challenges, providing Puerto Rico and other territories with the funding they need to avoid eligibility cuts is critical to maintaining coverage; this is especially true in Puerto Rico to prevent people from losing coverage while residents recover from the destruction and displacement caused by Hurricane Fiona.

Congress can help maintain recent gains in health coverage by passing policies including postpartum coverage, continued eligibility, and funding for Puerto Rico and the territories. As policymakers negotiate the year-end spending bill, they should consider other policies — such as a permanent reauthorization of CHIP and the inclusion of the proposed Medicaid Reentry Act — that could also help low-income people get, keep or access the coverage they have should.

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