Each morning when Christina Preston enters the West Community Opportunity Center that serves Ohio's Franklin County, she knows she and her staff are going to be flooded with calls and applications from people in desperate need of help.
Their despair could become even more acute next month as the national public health emergency comes to an end. That could lead to millions of people losing access to Medicaid and other benefits.
"We're planning for it as best we can, but the way we're looking at it right now is triage," said Preston, director of the local jobs and family services branch in Columbus, Ohio. "I don't even really want to imagine it right now. It's going to be huge."
Across the country, local agencies like Preston's are preparing for the unraveling of the expanded social safety net created in response to the pandemic — and, most significantly, the end of continuous Medicaid coverage, which expires Jan. 15, at the end of the public health emergency, unless extended by the Biden administration.
The provision, a requirement under the Families First Coronavirus Response Act that passed in March 2020, prevented states from removing Medicaid recipients from the program's rolls. At least 11 million people have enrolled in Medicaid since February 2020.
Up to 15 million Americans, including nearly 6 million children, could be at risk of losing their Medicaid eligibility when the protection expires, according to the Urban Institute, an economic and policy research think tank. The change could have an outsize effect on communities of color, the Urban Institute concluded.
Many will likely be eligible for other forms of subsidized coverage, the Urban Institute analysis found, but there is a concern that few people will know that they're in danger of losing Medicaid and are eligible for other types of health insurance. There have been few attempts to communicate this to those affected, they said, and not every state is approaching the problem the same way.
"The time to start planning for this was yesterday," said Cindy Mann, a partner at Manatt Health who served as director of the Center for Medicaid and CHIP Services during the Obama administration. "We really don't have more time."
In some cases, Americans who will be scrambling to assess their eligibility and potentially trying to find new health care plans could be met by states looking for ways to tighten their fiscal belts by aggressively removing people from the Medicaid rolls.
Contending with Medicaid disenrollment next year is "the looming monster," said Preston, who compared it to the overwhelming number of calls and cases the country saw when a record number of people made unemployment requests.
The trouble is that enrollees in crisis may also be met by local agencies suffering through staffing shortages and morale issues.
"Everything piling up has caused a lot of burnout, a lot of frustration and a lot of individuals to unfortunately leave their jobs," said Preston, who noted it takes 12 months to train a new caseworker.
Continued coverage vs. state budgets
As of now, states are required to keep people on the Medicaid rolls during the public health emergency unless they move out of the state or request to be removed. When the public health emergency ends, states will have 12 months to go through enrollment and determine everyone's eligibility status.
The Centers for Medicare and Medicaid Services reported that between February 2020 and May 2021, Medicaid and CHIP enrollment grew by 11 million people, or more than 17 percent, the largest enrollment increase over 18 months in the program's history. Federal spending on the program grew by 9.2 percent to $671.2 billion in 2020 because of the growth in enrollment.
But when the emergency expires, Medicaid recipients could be disenrolled from the program for an infraction as seemingly minor as not updating their personal information — something they haven't had to do since March 2020 — or missing a letter in the mail about their changing status.
This is of particular concern because many people moved during the pandemic, and a large number of those who receive Medicaid were also caught up in the eviction crisis, said Stan Dorn, director of the National Center for Coverage Innovation at Families USA, a left-leaning consumer health advocacy group.
"Lots of folks who are in tough circumstances are not going to get these notices," Dorn said. "If English isn't your primary language, if you have to upload paperwork and don't have good internet access, if you're working multiple jobs, this isn't going to be an easy nut to crack."
Government officials and health care advocates emphasized how large a shift in American health care coverage this would be and noted that this would occur while the country is still struggling with the spread of the coronavirus.
"This could be the biggest health care transition since the Affordable Care Act passed," Dorn said. "But this would be in a negative direction for coverage, instead of a positive one."
With the federal funding to state Medicaid programs expected to draw down quickly in the months after the public health emergency ends, some states are debating at what pace to go through the process of trimming the rolls.
In Ohio, the Republican-controlled Legislature included in the budget it passed earlier this year that the state would need to complete those redeterminations in 90 days, which advocates say is not nearly enough time to reach out to Ohio's 3.2 million Medicaid recipients and ensure that people who remain eligible aren't disenrolled.
Erica Crawley, a Franklin County commissioner who now oversees the jobs and family services program and fought against the 90-day provision in the budget when she served in the Legislature, said about 460,000 people would have to be processed within 90 days in her county, which includes Columbus.
With about 300 case managers, it would amount to more than 1,500 applications for each of them to process within 90 days.
"That's just for Medicaid. We're not talking about SNAP. We're not talking about cash assistance, and there are new applications that have to be processed, as well," Crawley said. "We're talking about maybe upwards of 15,000 hours of overtime that would need to be approved for these to be processed."
The Ohio Department of Medicaid declined to comment. The Ohio governor's office did not respond to a request for comment. Ohio state Sen. Tim Schaffer, a Republican and architect of the 90-day schedule, did not respond to a request for comment.
There is a concern among Republican states that a longer and more methodical redetermination process with a drawdown in federal funding could be extremely costly for states.
Ohio has gone so far as to appropriate $35 million for an outside vendor called Public Consulting Group. The company says it can automate eligibility redeterminations by checking third-party sources and finish the work within days. Of those that Public Consulting Group flags, the state would pay 10 to 20 percent of its savings to the company, according to the November newsletter published by the Ohio General Assembly Joint Medicaid Oversight Committee.
The Boston-based company did not respond to a request for comment.
It's one method that some consider controversial for its speed and payment system that some health advocates said was akin to paying a bounty for taking away residents' access to health care.
Across the country, however, federal and state officials are preparing for and debating ways to address a herculean administrative task that could have a huge bearing on states' budgets and the amount of people in their state with health care coverage.
The Centers for Medicare and Medicaid Services has reached out to states and attempted to work out a method of best practices. Most essential, officials said, was to spread the word about the upcoming disenrollment period and to ensure that state Medicaid offices and local agencies were informing people of their other health care options.
Daniel Tsai, the director of the Center for Medicaid and CHIP Services who was appointed in June, said his office has created a working group with about 25 state Medicaid agencies to discuss best practices on how to approach a problem that he called "unprecedented." They then meet with the remaining states on calls that include more than 700 people to relay their findings.
The focus for Tsai and Chiquita Brooks-LaSure, administrator of the Centers for Medicare and Medicaid Services, has been to ensure that those who remain eligible maintain coverage and those who don't transition to other forms of coverage, but there are challenges there, as well.
The agency prepared a checklist for states to encourage them to begin communicating the changes and to work closely with health care navigators, community groups and others to ensure as smooth a transition as possible.
The challenge is huge, Tsai said, but it has led to some innovation as they work to connect state Medicaid agencies with health care marketplaces.
"We try to be very cognizant of the realities on the ground, and also making sure we are using — I literally mean — every lever possible to help preserve coverage and access for folks," Tsai said.
Build Back Better: A guardrail and a wrinkle?
The Build Back Better Act, the Biden administration's landmark safety net bill, provides some guardrails to further protect Medicaid recipients and prolongs the federal funding provided to states, but it could prove to be an added administrative wrinkle.
The bill, which is unlikely to pass before the new year, would stretch the federal funding through the end of September, though it would go down by about half at the end of March and decrease further at the end of June.
It would allow states to terminate coverage only for individuals who had been enrolled in Medicaid for 12 consecutive months, limit the number of enrollees a state could drop from the program per month, require states to attempt to make contact through methods other than mail and require increased oversight and reporting to the federal government.
States, such as those that declined Medicaid expansion, could again decide to forgo the additional federal funds and avoid all of those guardrails and administrative burdens.
"States are certainly doing these calculations to decide whether it's worth it to adhere to the requirements in exchange for the enhanced [federal funding], or whether it makes more sense to try and conduct the redeterminations at a faster pace," said Jennifer Tolbert, associate director of the Kaiser Family Foundation Program on Medicaid and the Uninsured.
Whether or not states decide to participate, it appears Tsai and others at the Centers for Medicare and Medicaid Services are preparing to keep a close eye on what states are doing and whether they're dropping individuals without necessary follow-through.
In the meantime, Tsai said it was "unprecedented" the amount of work the centers and states have done together to try to stymie the flood of change in Medicaid coverage and ensure that people are connected to other forms of health care coverage.
"It's kind of a no-brainer when you think of how health care should work, and it's never been more important than in this context," Tsai said. "I really think we think we need to further encourage all of us and our state counterparts to be working in this way, not just now, but also in the future."