Hundreds of Thousands of Children Could Lose Coverage in Florida Alone as U.S. Approaches High Stakes Medicaid Unwinding

As readers of SayAhhh! know, Congress has given the green light to states to begin checking eligibility for all Medicaid beneficiaries who have been protected from disenrollment by federal law since the Families First Covid Relief Act passed in March 2020. Terminations can begin on April 1, 2023; states have a year to complete the process. We’ve got a whole section of our website dedicated to this issue, and as we explained about a year ago in this paper, an estimated 6.7 million children are at risk of becoming uninsured during this process. That would more than double the number of children who are uninsured. Parents and other adults are of course all at risk too.

Yes, that is a huge number! We came to that estimate by applying churn rates from before the pandemic to the total number of kids protected by Medicaid’s continuous coverage provision. That is why we feel it may even be conservative since this is an unprecedented undertaking; states are very understaffed, and, in some cases, anxious to dump people off.  And most children who lose coverage will remain eligible for Medicaid or CHIP but will be disenrolled due to bureaucratic hurdles or other procedural issues.

So, it is not a foregone conclusion how many people will lose coverage – what happens, at least for children, will depend on how states handle this – since eligibility systems for both Medicaid and CHIP are entirely state-run. Adults are more likely to move to the federal Marketplace for coverage since income eligibility for Medicaid is lower for them – and in non-expansion states nonexistent except for very poor parents or adults that are pregnant or meet SSI disability standards.

Tricia Brooks and I desperately hope that our prediction turns out to be wrong. As states move into high gear, we will start getting information very quickly about their plans. This week Florida publicly released its state unwinding or “Medicaid Redetermination” plan for the first time. There are lots of unanswered questions about the plan, but to give you a sense of the magnitude of the potential coverage losses and what lies ahead let’s dig into the details.

The state’s plan says it will prioritize two groups that the state thinks are ineligible for renewals and are top of the list for possible termination (see p. 10). The first group includes families and individuals that the state has data showing are over income as of December 2022, and there are more than 900,000 cases in this category (so this is actually more than 900,000 people but the state doesn’t provide any more information on how many of cases are families.) Because Florida’s eligibility for parents is so low (30 percent of the poovery line) and Florida has not expanded Medicaid, some of these 900,000 are parents and will likely fall into the coverage gap. Some children in families whose income has risen slightly will be eligible for Florida Healthy Kids (Florida’s CHIP) or the federal Marketplace. Finally, some will be women who had Medicaid postpartum coverage that had retained it through the continuous coverage provision and will no longer have that protection.  The state will have to make sure that the new 12-month postpartum coverage is implemented properly so that new moms do not get lost in the shuffle. The second group the state is prioritizing is the 850,000 cases where individuals have not responded to requests to update their contact information as part of their regularly scheduled annual determinations (which have continued in Florida as many states have done but just without terminations). This group likely includes many families whose children remain eligible but the state’s message has not gotten to them. Here’s a point I agree with the state on — parents shouldn’t panic about their children’s coverage. While they may no longer have coverage themselves, their children are likely eligible for Medicaid or Healthy Kids as long as they can jump the bureaucratic hurdles.

How quickly the state will push these cases through the redetermination process is not clear from the plan. And that is a key question. One clue to the answer was provided by Florida Medicaid Director Tom Wallace when he told members of a Senate health care spending panel Wednesday: “They will probably come off relatively quickly.”  What is clear is that 1,750,000 cases (so surely more than 2 million people given most of these cases are probably families) are at very high risk of losing their Medicaid when the state starts terminations at the end of April.

Because Florida is not an expansion state, children make up an even larger share of the state’s Medicaid enrollment – the most recent CMS data for August 2022 shows that 62% of Florida’s Medicaid enrollees are children!! So, it would be reasonable to hypothesize that at least half of the 2 million people whose cases are at the front of the list to be cut off are children. Yikes. (BTW Florida, please be more transparent with your data ASAP so we don’t have to hypothesize.). Federal estimates project that 72% of children who lose Medicaid will remain eligible but will lose to bureaucratic snafus! Communities of color, especially Latinos, are at greater risk of inappropriate coverage loss as well.

One issue the state must address before the unwinding starts is to update the Medicaid and CHIP income eligibility guidelines for 2023 with the new poverty thresholds just released by the federal government earlier this week. (My colleague Tricia Brooks blogged about the importance of this issue for all states.) Because of, well you know, inflation, these thresholds went up by c. 8% — the largest jump in many years. So, Florida’s income assessment in December 2022 will not reflect that some of these families will remain eligible under the revised guidelines. And for those who have not responded to the state’s request for updated contact information the state must try harder.

Florida already has one of the highest uninsured rates in the nation overall and ranks among the bottom 10 states for children. Governor DeSantis must decide whether he wants the state to take the time and put in the effort to work collaboratively with stakeholders to minimize health coverage loss – especially for children. Or not.

[Editor’s Note: Florida residents should contact a navigator or ACCESS Florida Customer Call Center at 1-866-762-2237 if they or their children are at risk of losing Medicaid coverage.]

Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy.