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Medicaid Workforce & the Public Health Emergency “Unwinding”

August 15, 2022 |  By Heather Bates, MSW and Sarabeth Zemel, JD

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For more than two years – the duration of the COVID-19 pandemic – Medicaid programs across the U.S. have provided continuous coverage for Medicaid enrollees. In exchange for enhanced Medicaid funding, states agreed to not disenroll anyone as long as the federal public health emergency (PHE) remained in effect. As a result of this requirement, in tandem with the medical, physical, and socioeconomic toll the pandemic caused to individuals and families, Medicaid enrollment skyrocketed to more than 88 million individuals nationwide as of April 2022. This is despite some states not even adopting the ACA’s Medicaid expansion.

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Once the PHE ends though, state eligibility workers will need to process a large volume of Medicaid redeterminations and begin disenrolling those who are no longer eligible for Medicaid coverage.

This monumental task, also known as the unwinding, is complicated by workforce capacity, as well as other issues. Just like virtually every other sector of the U.S. economy Medicaid agency workforce has been losing staff since the pandemic began. According to survey results published by the National Association of Medicaid Directors, this spring the Medicaid staff vacancy rate is as high as 30 percent in some states. And 57 percent of state and local workers are considering leaving their jobs due to the pandemic, either choosing to retire, change jobs or leave the public sector entirely. States are preparing to meet this challenge by taking steps to boost staff resources – 30 states reported taking actions that include approving overtime, hiring new eligibility workers or contractors, or borrowing staff from other agencies.

States are beginning to release plans for how they are preparing for unwinding activities, including bolstering their workforce to ensure sufficient capacity. Michigan’s legislature appropriated more than $20 million in additional funding to support new county eligibility staff, staff re-assignments, and training for the PHE redeterminations. Texas identified workforce as a key challenge and is employing multiple strategies: conducting job fairs in areas with high retention, doing on-demand hiring to boost recruitment, allowing clerical staff instead of eligibility workers perform data entry and interview scheduling, and making IT system changes to result in faster processing times.

Because of this brand-new workforce and the fact that states have not disenrolled anyone from Medicaid during the last two years, there is the high potential for errors once states begin reprocessing redeterminations. New Medicaid eligibility staff have little to no experience processing and issuing proper denials of coverage.

Determining Medicaid eligibility is complex, as several current headlines indicate. Perennial problems with glitchy electronic systems, following proper due process, timely and clear notices, and human errors abound. This can result in systemic errors, gaps or delays in coverage, and erroneous enrollment decisions. As these types of problems persist in a state post-PHE they may compound the workforce issues.

Recently, in Oregon, a revamp of the ONE public benefits eligibility system that resulted in software errors and inadequate staff training around the updates to the system, resulted in major errors for one of the most extremely vulnerable populations: those who are elderly and trying to qualify for Medicaid long-term care benefits. NPR just recently profiled a family in Tennessee who lost out on TennCare coverage (Tennessee’s Medicaid program) prior to the pandemic due to a clerical error that sent their renewal paperwork to the wrong address. The story also highlights the long history of problems with eligibility redeterminations in Tennessee.

Right now, states are partnering with Medicaid managed care plans and other partners to make sure current Medicaid enrollees are updating their contact information. When the PHE ends, this information will be critical for making sure any renewal paperwork gets to the proper place (although as the TennCare story highlights even that can be difficult in normal times).

Once the PHE ends, there’s a role for everyone to make sure the unwinding goes smoothly, and redeterminations are done correctly. In addition to ensuring they’re staffed up and IT systems are running smoothly, states will need to take extra care to follow due process. Advocates will also need to be on guard to make sure that states are following proper procedures and helping individuals navigate the appeals process. Clinics will need to watch out for their patients who get denial notices and direct them to help. Enrollment assisters, Navigators, community health workers and others who facilitate enrollment can help confused consumers with questions and assist those losing Medicaid coverage in finding new coverage options, such as through the marketplace.

Transform Health is tracking and monitoring issues related to the unwinding. Watch this space for an upcoming blog about another facet of the unwinding: how some states are trying to minimize coverage disruptions when the PHE ends.

If you would like to learn more or work with Transform Health, please contact Heather Bates at heather@transformhc.com.