Medicaid and COVID-19

One of Medicaid’s many strengths is its ability to help states respond to public health epidemics. Through Medicaid, federal funds are available on an open-ended basis to match state costs of immunizing, testing, diagnosing, and treating over 71 million low-income Americans in the event of an outbreak of an infectious disease. Which is a good thing, because the opioid crisis is not yet behind us, and the novel coronavirus disease (COVID-19) is now upon us.

Here’s what the Centers for Disease Control and Prevention (CDC) website had to say about COVID-19 as of March 9:

“More cases of COVID-19 are likely to be identified in the coming days, including more cases in the United States. It’s also likely that sustained person-to-person spread will continue to occur, including throughout communities in the United States. It’s likely that at some point, widespread transmission of COVID-19 in the United States will occur. Widespread transmission of COVID-19 would translate into large numbers of people needing medical care at the same time. … Public health and healthcare systems may become overloaded, with elevated rates of hospitalizations and deaths. Other critical infrastructure, such as law enforcement, emergency medical services, and sectors of the transportation industry may also be affected. Healthcare providers and hospitals may be overwhelmed. At this time, there is no vaccine to protect against COVID-19 and no medications approved to treat it. Nonpharmaceutical interventions would be the most important response strategy.”

Here’s what the Centers for Medicare & Medicaid Services (CMS) Medicaid website had to say in its “Fact Sheet” on Medicaid and CHIP Coverage and Benefits relating to COVID-19 as of March 9:

“For information on benefits offered in your state, where to access services and how to apply for coverage in your state, see Medicaid.gov. https://www.medicaid.gov/about-us/contact-us/contact-state-page.html

Not particularly helpful for those wanting to know, say, whether testing for COVID-19 is covered (compare this to the Informational Bulletin issued in 2016 in response to the Zika virus). But it does reflect a basic reality about Medicaid. States have broad flexibility in administering the program; as a result, there is considerable variation in eligibility and benefits from state to state; and CMS does not maintain a Medicaid benefits database that would enable it to answer such a basic question. (The Kaiser Family Foundation does maintain such a database, which is current as of 2018.)

What little the CMS “Fact Sheet” does tell you is illuminating, however. Screening and diagnostic services are an optional benefit, and not all states cover them (per the Kaiser database, in 2018, 42 states covered this benefit for adults, 3 did not, and 6 did not report). Under the EPSDT benefit these services are covered for children in all states. So it appears that, for adults, Medicaid may not cover COVID-19 testing in at least three states (Alabama, Nebraska, and Utah).

According to the CDC, “No specific treatment for COVID-19 is currently available.” To date, most of the reports to the CDC regarding the clinical management of patients with COVID-19 involve patients hospitalized with pneumonia. All states are required to cover medically necessary inpatient hospital services for both children and adults eligible for Medicaid.

Although there is currently no vaccine to protect against COVID-19, when one is eventually developed, the question will be whether Medicaid will cover it and the cost of its administration. The answer in the case of children is simple: Recommended vaccines are covered without cost sharing. In the case of adults, the answer is not so straightforward.

As the “Fact Sheet” makes clear, in the case of expansion adults, states must cover preventive services, including vaccinations without cost sharing. For non-expansion adults, coverage of preventive services, including immunizations, is optional. (The Kaiser database results for diagnostic and screening services in 2018 cited above apply to preventive services as well).

Which brings us to the fundamental issue: coverage. Questions as to which state Medicaid programs cover testing (or eventually, a vaccine) for COVID-19 matter only if an individual is enrolled in Medicaid. In 14 states some 2.3 million uninsured non-elderly adults with incomes below the poverty level—both parents and adults without dependent children—are not eligible for Medicaid because their states have not taken up the option to cover them, even though the federal government will pay 90 percent of the cost.

For these Americans in poverty, the scope of Medicaid coverage is academic; they are uninsured and will therefore be dependent upon state and local public health resources for access to diagnostic testing. As public health experts recently explained in an open letter to Vice President Mike Pence, “It will be critical for policymakers to ensure comprehensive and affordable access to testing, including for the uninsured. Control efforts will be less effective if some fail to seek appropriate diagnosis or care due to large out-of-pocket costs or copays.”

The emergency appropriations bill passed by the Congress and signed into law by the President last week will help these states cover some of the costs of diagnostic testing of the uninsured. But this infusion of funds—$950 million to state, local, and tribal public health agencies—while absolutely essential, is ultimately no substitute for Medicaid coverage of screening, diagnosis, prevention, and treatment services for all low-income Americans, not just those in 37 states.

Unfortunately, CMS Administrator Seema Verma has spent the past three years doing her best to undermine the ability of the Medicaid to help the nation respond to public health emergencies by covering all low-income Americans. The Administrator makes no secret of her belief that the purpose of Medicaid is not to provide coverage to all low-income Americans; instead, she has been on a mission to undermine coverage of those she disparages as “able-bodied.” To disenroll this population, she has attempted, without success, to impose work reporting requirements as a condition of eligibility. In fact, without the intervention of the courts, hundreds of thousands of low-income Americans would be facing COVID-19 epidemic without insurance coverage.

More recently, Administrator Verma has proposed regulations that would severely disrupt existing revenue sources for states’ share of their Medicaid costs, likely leading to cuts in eligibility, benefits, and/or payments to providers and plans. Among investors, the COVID-19 epidemic is widely expected to slow economic growth; if these expectations prove correct, state tax revenues will decline, making it more difficult for states to finance their Medicaid programs. To further undercut state Medicaid programs during an economic downturn does not seem to be a smart decision.

In normal circumstances, this relentless drive to reduce Medicaid coverage and take down what Sara Rosenbaum has described as the “Nation’s Largest Health Care First Responder” would be simply mean-spirited. In the midst of a COVID-19 epidemic, it is a direct threat to public health.

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