Rural Health Policy Project

Mapping the Barriers to Renewing Medicaid Coverage for Rural Arizonans When Continuous Coverage Ends

By Zaida Dedolph Piecoro and Bryna Koch

Currently, half of those at risk of coverage loss at the end of the public health emergency (PHE) in Arizona are children under 19. Like many others, we at Children’s Action Alliance and our partners at the University of Arizona, Arizona Center for Rural Health are strategizing to protect Arizona children from health insurance coverage.  

Despite improvements in health insurance coverage since the Affordable Care Act, racial and ethnic disparities in coverage status persist. In Arizona, they are most pronounced among American Indian/Alaska Native (19.8% uninsured) and Hispanic children (10.3% uninsured) compared to 6.1% among White children and 7.0% among non-Hispanic children.

Arizona faces many challenges when it comes to health insurance coverage and healthcare delivery. Arizona is geographically large but has relatively few political subdivisions. Arizona’s fifteen counties span nearly 114,000 square miles. Arizona also experiences healthcare workforce shortages statewide. These shortages are particularly severe in Tribal and rural areas.

Given this context, it is more important than ever to ensure Arizonans stay covered. 

The state’s Medicaid program, named the Arizona Health Care Cost Containment System (AHCCCS), has adopted a proactive approach to planning for the end of the PHE. Though AHCCCS has stopped disenrolling participants during the PHE, they continue to send renewal notices and requests for information to participants. These provide a solid paper trail to guide our outreach. AHCCCS has also actively partnered with Managed Care Organizations (MCOs) and Federally Qualified Health Centers (FQHCs) to identify enrolled members or patients at risk of coverage loss. Many AHCCCS MCOs have hired CHWs specifically to aid in this effort. 

AHCCCS has provided Children’s Action Alliance summary data on members at risk of losing coverage. This data helped create a general overview of the 600,000+ Arizonans at risk of coverage loss at the end of the PHE. Per our initial analysis:

  • 44% (265,230) of those at risk of Medicaid or CHIP coverage loss in Arizona are children under 19
  • 6% (35,169) are older adults
  • 3% (17,676) are experiencing homelessness
  • Though individuals who identify as American Indian / Alaska Native alone make up about 5.3% of Arizona’s population, they represent 10.1% of those at risk of coverage loss 
  • Though Black / African American individuals make up 5.4% of Arizona’s population, Black individuals represent 10.7% of those at risk of coverage loss

We now know more than ever about the barriers to enrollment and renewal in Arizona, in part due to the relationships that Children’s Action Alliance has built with AHCCCS and KidsCare (CHIP) members in every corner of the state through policy advisory councils. During an AI/AN caregiver advisory council meeting, several individuals noted that the enrollment process has been complicated due to the closure of in-person enrollment locations on and near Tribal nations. 

“Small government” ideology has led to disinvestment in government agencies, and the pandemic’s impact on staffing led to closures of several public-facing AzDES office locations. Additionally, many Tribal governments remained under public health emergency orders for far longer than the state government, meaning that in-person services at Tribal business offices were heavily restricted. Despite hours-long wait times for assistance by phone, AHCCCS and the Arizona Department of Economic Security (AzDES), which also screens for Medicaid and CHIP eligibility, continued to encourage participants to re-enroll by phone. 

To better understand the impact of these office closures, the Arizona Center for Rural Health (AzCRH) used ESRI ArcGIS (GIS) to map the locations where more than 15% of AHCCCS members were likely to lose coverage. In total, 37 census-designated places were identified that met these criteria. Of these, 24 are in Northern Arizona, a region of the state with significant Tribal populations. AzCRH then mapped the drive-time from these locations to an AzDES public-facing offices, and overlaid FQHCs and Tribal health facilities to identify other resources available in each area. The average drive time to an AzDES office is upwards of 30 minutes, and as high as 70 minutes. In Apache, Coconino, and Navajo counties, where 20 of the high-coverage loss locations are located, there are also few options for public transportation.

Additionally, they used U.S. Census data for the primary tracts in the locations where more than 15% of AHCCCS members were at risk of losing coverage to provide context about the population resources in the area. They found that in addition to having high proportions of AI/AN and Latine individuals, high-coverage loss areas reported less access to key resources like internet access, a home computer, or a vehicle. U.S. Census data for these 20 locations show: 

  • 41.4% of households have no computer (compared to 8.1% in Arizona) 
  • 63.8% of households have no internet (compared to 14.4% in Arizona)
  • 13.6% of households have no vehicle (compared to 5% in Arizona)
  • 42.4% of households have one vehicle, which may be used for transportation to work (compared to 33.3% in Arizona). 

AzCRH shared this data with the directors of AHCCCS and AzDES directors in an effort to inform outreach and in-person enrollment in these regions. Efforts are underway to provide increased mobile enrollment assistance. In the meantime, AzCRH and CAA are mobilizing partners to engage in targeted outreach to communities at risk of coverage loss. 

As Arizonans, we are more than accustomed to making the best of our adversity– most of us are desert dwellers, after all. We will continue to leverage relationships with agency staff and patients to better understand the demographic and geographic makeup of those at risk of coverage loss and prevent unjust disenrollments. 

Zaida Dedolph Piecoro is the Director of Health Policy at the Children’s Action Alliance. Children’s Action Alliance is an independent voice for Arizona children that identifies and eliminates barriers to the well-being of children and families and creates opportunities through partnerships and policy solutions.

Byrna Koch is the Research Program Administrator at the Arizona Center for Rural Health. Situated within the University of Arizona, Mel and Enid Zuckerman College of Public Health, Arizona Center for Rural Health’s core mission is to improve the health and wellness of Arizona’s rural and underserved populations.