Rae Woods (01:02):
From Advisory Board, we're bringing you a radio advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. Since 2020, the coverage landscape has changed a lot, but no change has compared to what we've seen in Medicaid, both the massive rise in Medicaid enrollment, and of course what we now see after the public health emergency. Six months ago, states could start disenrolling beneficiaries. And that moment sparked a ton of change and a ton of transition that everyone in the healthcare industry is still grappling with, including the very patients that we serve. And that's why this week, I've invited health plan experts, Chelsea Needham and Sally Kim to discuss where we are with Medicaid redeterminations and where we need to go next. Hey, Chelsea. Hey, Sally. Welcome to Radio Advisory.

Sally Kim (02:02):
Hey Rae, thanks for having us.

Chelsea Needham (02:04):
Hi, Rae.

Rae Woods (02:05):
Be honest with me, you two are on the health plan team. How the hell has the last six months been for you?

Chelsea Needham (02:15):
It's been a whirlwind to sum it up.

Sally Kim (02:18):
Yes.

Rae Woods (02:20):
Pretty busy I bet. I bet. Never a slow news cycle in healthcare, but the last six months in particular, I perhaps do not envy you and your research team.

Chelsea Needham (02:32):
It's a lot of fun.

Sally Kim (02:33):
Especially since we're doing Medicaid research right now. So, a busy time.

Rae Woods (02:40):
And that is because we're in the midst of massive changes in Medicaid because of Medicaid redeterminations, which is the process of sorting through people who are actually eligible for Medicaid or not. And that process in and of itself is not new, but it obviously got a whole lot more complicated this year when just six months ago, the COVID-19 public health emergency ended, and with it, the rule that prevented states from terminating coverage. I'm trying to think back to where we were six months ago, and I feel like all anyone could talk about, the number that I saw everywhere, was 18 million. 18 million people are going to lose Medicaid coverage. Six months later, where do things actually stand?

Chelsea Needham (03:29):
As I mentioned before, Rae, it has truly been a whirlwind, and to be honest, it's been more like a whiplash and everybody is trying to gain their footing and catch their breath. Prior to the public health emergency, we had our routine of Medicaid guidelines, but when the public health emergency started with the expansion of those guidelines and more people being able to qualify for Medicaid, we saw a huge jump in Medicaid enrollment. And now we are six, seven months outside of the end of the public health emergency, and that 18 million that we're expecting to see disenroll right now we're probably around 9 million in terms of disenrollment that we've seen so far.

Rae Woods (04:13):
Is that where we expected to be at this point?

Chelsea Needham (04:17):
So before the public health emergency ended, everyone had all these different guesses of where we were expected to land and trying to understand where this percentage was going to be for the amount of people that would actually be disenrolled. And so initially I think we were more along the lines of seeing an 18 or 20% disenrollment rate, but right now-

Rae Woods (04:39):
That's what we expected?

Chelsea Needham (04:39):
Yes.

Rae Woods (04:39):
We expected to see 18%?

Chelsea Needham (04:42):
Yes, but right now we're probably seeing something closer to the 40% rate of disenrollment. So we've had, as I stated, 9 million people disenrolled, and that's a much higher rate than what we initially guessed.

Rae Woods (04:54):
Let me actually restate that. You're saying that six months in, twice as many people are being disenrolled than we initially expected in this first six month period?

Chelsea Needham (05:08):
That is exactly what I was saying.

Rae Woods (05:10):
In fact, I think there's been such whiplash that the federal government stepped in and said, "Hold on, hold on. We actually need to slow down."

Chelsea Needham (05:20):
So CMS has actually, yes, passed down some information given what they've seen. So we have about 30 states, which actually includes DC as well, who have been directed to actually pause their disenrollment because of the issues that we've seen with autorenewals and process errors that have been discovered. So with that, we're actually expecting for about 500,000 children and adults to actually regain coverage because of those procedural disenrollments.

Sally Kim (05:46):
Yeah, because one thing I want to clarify is that it is the rate that is more alarming rather than the number. So we're actually not at the point that we expect. When we talk to plans, they think they'll land anywhere between losing 20 to 30% of their Medicaid membership. But this rate is higher than expected because a lot of the states that are being a little more aggressive, they started faster. So they're the ones that are further into their disenrollment. Also, these states have decided to start with the folks that are most likely to be not eligible. So that is why we're seeing a higher rate. Now, we do anticipate that the rate will decrease, especially now with the pauses in place.

Rae Woods (06:28):
And it's important to recognize that states have good reason to be very careful about who is eligible and who is not, because states have to balance their budget every year and Medicaid is a huge, huge portion of state budget. So it makes sense to me that, all right, let's get in right away and figure out who really is still eligible for Medicaid coverage, which is perhaps one of the reasons why the rate is so high right now. But I'm also hearing another reason why perhaps more folks are getting disenrolled from Medicaid than expected. What is this other reason?

Sally Kim (07:08):
It's all paperwork, honestly, which is pretty depressing because you don't want folks to lose coverage because of a paperwork issue. That's very different than them losing coverage because they're not eligible anymore. So a lot of folks... I've seen estimates of up to 50% are doing redeterminations for the first time and it's a complicated process. On top of that, imagine if maybe you're working multiple jobs or you don't have access to reliable internet and you're also trying to do all this paperwork. I think over 70% of folks who are being disenrolled right now are for procedural reasons. So that is-

Rae Woods (07:47):
Wait, wait, say that number again. How many people are being disenrolled for procedural reasons?

Sally Kim (07:51):
72%. So that's the number-

Rae Woods (07:53):
So, really high.

Sally Kim (07:55):
Yeah.

Rae Woods (07:55):
And again, you're talking about folks who are actually eligible for Medicaid and need and rely on this service to get access to healthcare, but it's just administrative stuff that has gotten in the way and actually resulted in them losing their coverage entirely?

Sally Kim (08:13):
Yes. Perhaps eligible, we don't know.

Rae Woods (08:16):
Perhaps eligible. What happens to that person if they're disenrolled?

Chelsea Needham (08:19):
So there are actually a couple different options that can happen to someone who is disenrolled from Medicaid. I think the first thing that people assume is if that someone is disenrolled from Medicaid that they are going to become uninsured. But there's actually a fair amount of people who are on Medicaid who also have another insurance as well. But if, for instance, a person does only have Medicaid coverage, there are options available for them to go to potentially an employer sponsored insurance plan. They could also receive a plan from the marketplace. If they have a spouse who has coverage, they could also switch to a plan underneath their spouse if that's available underneath an employer as well. So I think there's a big distinction to make when people talk about disenrollment versus being uninsured, but there are a lot of people who may still end up uninsured if they are disenrolled from Medicaid. So that's not to say that everyone who is disenrolled will find another insurance plan. There is still a portion of people who will go without insurance as well.

Rae Woods (09:24):
I appreciate this clarification so, so much. And I appreciate what Sally said earlier, which is, "Hold on, we can't just look at these numbers kind of in a vacuum." And if I think back to that initial number that was thrown around a ton when we were expecting the official end of the PHE, one of the things that really frustrated me was folks just said 18 million losing Medicaid and didn't add anything else to the end of that sentence, not realizing that a lot of those folks actually could be eligible for something like employer sponsored insurance and the reason why they stayed on Medicaid was again, because states weren't allowed to disenroll anyone from Medicaid, a big reason why, to Sally's point, states were trying to figure out who those folks were to remove them from Medicaid as quickly as possible.

(10:10):
So we have to keep thinking about this context behind the numbers. That said, the word that I think is most important is one that you said, Chelsea, which is whiplash. We're of course seeing this whiplash in a ton of folks losing Medicaid coverage, but we're also going to see some of those folks come back, especially if they lost coverage because of paperwork reasons like Sally said. What does this kind of second layer of whiplash mean?

Chelsea Needham (10:38):
That second layer of whiplash also comes from the fact that sometimes renewals are not done in a timely process. That could be an issue with patients receiving the proper forms in order to fill out information to confirm that they are still eligible for Medicaid. If those forms lapse or they're not received by the health plan or the state, then those members can become disenrolled simply because the paperwork or the information was not received, or the health plan or the state has an incorrect address for where a member is receiving these forms or an email address, and they're just not getting the necessary information in order to confirm that they are still eligible for Medicaid. So that's the other part of the whiplash that we'll see. And once those members are actually, finally reached, they also have the potential to have their insurance reinstated and then retroed back to the time period in which their insurance lapsed. So it creates a lot of issues.

Rae Woods (11:33):
So maybe what I'm hearing you say is we're six months in, but we are nowhere near done, right? The dust is not going to settle for some time because of all this whiplash. Is that right?

Chelsea Needham (11:45):
I would agree, yes. Sally?

Sally Kim (11:47):
Going off of what Chelsea said, and there's this grace period for most states. So even after folks have been disenrolled, if they can get their paperwork back in order within the next 60 to 90 days, then they do get coverage for that time span, which is good for patients, of course, and we need that. But it's a huge headache for plans and providers because sometimes a provider might not even know if they will or will not be reimbursed, and if so, by which purchaser, because that member might have gone and gotten other insurance during that time as well.

Rae Woods (13:34):
This really is a headache, and I think one other layer that adds to this collective headache that we're all feeling is that these Medicaid changes are happening at a state by state level, and we are seeing huge differences among states, different levels of progress, huge variation. How do you want us to think about the fact that things do look different when you look at different states?

Chelsea Needham (13:59):
Yeah, I think there's so many things to consider. When we talk about the differences between states outside of just the political climate of things that exist across states, there's also the importance to unpack whether or not a state is expanded or if they have expanded Medicaid in their state. When we talk specifically about states who have expanded Medicaid or the states who have not expanded Medicaid, for example, if we look at states like Florida or Texas, these states have not expanded Medicaid. And that means that they have more on the line that they're thinking about, because financially there are more implications for those members who remain on Medicaid who are no longer eligible for Medicaid. So there is greater force to draw from in order to understand if these members should remain on Medicaid given their implications for how they will have to pay for these members because they're remaining on Medicaid and they should not be.

Rae Woods (14:57):
And perhaps those are the states that have perhaps the biggest rate of change because to your point, they have the strongest reason to actually look at their Medicaid coverage.

Chelsea Needham (15:09):
Correct. And traditionally, we've also seen as well state by state differences in states allowing managed care organizations, so Medicaid plans, to actually assist with the Medicaid process. Traditionally, we've seen across a lot of different states that MCOs have not traditionally been involved in the disenrollment process. So the changes that we're seeing state by state can play a role depending on how much the MCO is contributing to assisting the state with these disenrollments, which has not traditionally been the case in disenrollments and renewal processes in past years. So whether or not they're pulling in additional resources like the MCO to assist with the process plays a role just as well as if the state has expanded or not expanded as well.

Sally Kim (15:54):
I'm glad you mentioned this, Rae, because Medicaid is the most state dependent line of business, so it's really hard to have this conversation without touching on the state by state nuances.

Rae Woods (16:06):
And I want to talk about what those nuances and this headache and this whiplash means for healthcare stakeholders. And for me, I wonder if one of the biggest headaches is going to actually impact the big, large national plans, the ones that are going to have to manage this complexity across several states that are experiencing this whiplash at different rates at different times for different populations. All I see is complexity and perhaps that's putting it nicely. How is this going to impact the big national plans or how is it already impacting the big national plans?

Chelsea Needham (16:41):
Yeah, that's a good question, Rae. I think across the board, whether it's a national plan or not, that logistically it's going to cost everyone a lot of money. With national plans, of course, they typically have a larger member pool, and so they have to consider the expense that comes with having that population. So it's important for them to be able to get things right the first time so that they don't have to deal with that whiplash of months of backed up paperwork or having to redo things because of procedural issues. So there's a lot of money on the line for national plans as well.

(17:16):
And then I think one of the other things that we want to look at, I talked about expanded states and non-expanded states as well. So with national plans, it's important again, because their populations are typically larger, you might see a different mix in their member population. So if we look at non-expanded states, for example, we'll see that those memberships may look mostly like children and pregnant mothers. And so it'll be less holistic than a state that has expanded Medicaid. And so those populations will be made up a lot of different types of memberships. And if you're a national plan, you probably have to see more of that given your membership and the larger pool of members that you see.

Rae Woods (17:58):
These are two points I'm not hearing a lot about, right? First, the cost that comes with the logistics of managing the whiplash and the long-term effects of what it's going to mean when the risk of your population looks different in 2024 than it did in 2020, 2021, 2022, and part of this year. Is that right?

Chelsea Needham (18:21):
That is correct. So there's two different ways that whiplash is showing up, but then that whiplash is also just trickling down to a lot of different areas, as we talked about earlier, with providers, with other stakeholders, and other lines of businesses as well.

Rae Woods (18:34):
Sally, you speak with health plans every day. Are health plans prepared for this whiplash, this headache, this mess?

Sally Kim (18:46):
Honestly, it's hard to answer because this is something that plans deal with on an annual basis.

Rae Woods (18:53):
And they had time to prepare for, right? We talked about this long before April of this year.

Sally Kim (18:59):
Right. So they had to do it every year. They've always dealt with the state by state nuances even if they are a national plan. I think what is different to this year though is this scale. So yes, right now everything's in flux. I do think it will go back to normal, and we will get through this, and we'll be fine, and plans will still be alive and making money off Medicaid.

(19:23):
I think the problem is this transition period, and this time right now, it's just hard for everybody. So it's hard for providers who don't know if they're going to get paid, when they're going to get paid. It's hard for patients who might have to switch coverage or they might not even know that they need to switch coverage. It's hard for plans as well. And I think the thing that we're missing a little bit as I talk to these Medicaid plans is right now we're trying to put out this fire that is free determinations and we have to do that. And plans are working with states very differently than in years past because states are giving them more flexibility and autonomy to help because they need that help right now.

(20:05):
But I think what we're missing is even after all of this is over, we're still going to be dealing with the just as big problems we've always had in Medicaid. So these are perennial challenges that right now I feel like are temporarily put on the back burner because we have to put out this immediate fire. The winners in Medicaid will be the ones who can quickly go back to thinking about long-term strategy after this is over.

Rae Woods (20:32):
What are some of those perennial issues that are not going to get better as we're focused on this fire right here, and perhaps the water is rising in the background for some of those perennial issues in Medicaid?

Sally Kim (20:43):
Just to name a few off the top of my head, access has always just been harder in Medicaid because of the lower reimbursement rates. Social supports, relevant for every line of business, but as you can imagine, comes up very frequently in Medicaid. And then one that we're hearing about, I shouldn't even group these two together, but closing care gaps and then maternal health care gaps specifically, these are things that will make or break whether we're winning Medicaid bids or not for years to come, even after we get through the current emergency of redeterminations.

Rae Woods (21:19):
And to your point, it is going to have an impact on many aspects of healthcare, and I want to give voice to some of those other stakeholders. You just mentioned some of them, Sally, so let's talk about them. I want to start by talking about providers. And I will say from my conversations, I'm just hearing very, very different things. Some providers are saying, "Hey, this might change my coverage mix for the better. This is a good thing if I'm going to see folks getting more private insurance versus last year, if these are folks who can get employer sponsored insurance as opposed to Medicaid." On the other hand, a lot of folks are very worried about the uninsured rate increasing, as Chelsea pointed out. How are providers reacting to all of this as we're in this transition period and eyeing where we're going to ultimately end up?

Chelsea Needham (22:07):
Rae, I think all of that can be true, and we've heard some of that as well. But even if a provider's mix is going to change, the fact is they still have a stake in the fact that they members are becoming disenrolled from Medicaid, and that's just because again, the whiplash that we're expected to see. If a member is disenrolled from their Medicaid plan, there's a potential that they can be retroed on that plan, which means that'll create a lot of confusion for that provider when it's time for them to submit claims to the insurance plan, if they're submitting it to the wrong insurance plan and they have to go back and submit corrected claims. And so it just becomes a very big administrative burden and can lead to a lot of administrative inefficiencies. So I really think that the more people can think about it as not just being a Medicaid disenrollment issue, but being an everybody issue, can help people pull their equal weight in contributing to making sure that patients land where they're supposed to be.

Rae Woods (23:02):
Especially since you pointed out, Chelsea, that the administrative burden is not just annoying, it's expensive. And so providers have a stake in the game as opposed to just saying, "I'm frustrated," as someone else figures this out, right?

Chelsea Needham (23:17):
Correct.

Sally Kim (23:19):
And this is a good example of how even frenemies can get together if there is a mutual challenge that they're trying to overcome. Because we've heard from plans across the country that providers this year are way more engaged and willing to help with redeterminations than ever before. And I don't think it's just because they want to keep their own membership. I think it is because they genuinely know that a lot of members are reliant on them and they are the best point of contact who gets the most in-person interactions with these patients.

Rae Woods (23:54):
There's a stakeholder that we've mentioned a few times in this conversation, and I want to make sure they get their own breathing room, and that's the people. All of the changes we've been talking about, the churn that we're talking about, it's affecting stakeholders in healthcare, it's affecting executives, it's affecting health leaders, but it's also impacting real people. What does this mean for patients as we're in this transition period?

Sally Kim (24:20):
This is hugely impacting patients. Honestly, I wish I spent more of my day speaking to patients rather than plans and providers, because I can't even imagine how difficult this is for them. And even though most of the folks who should be on Medicaid and are eligible will end up back on Medicaid, that transition period where they're unsure where they are going to be or if they will get Medicaid again, is going to impact their care continuity, their medication adherence, their provider relationship. And even prior to this, we've heard from Medicaid patients that they're scared of getting any mail from their plan or state because they're worried that every mailing could be them getting cut off. And it is just sad that now that could actually be happening. So imagine how much distrust there will be after this process.

Rae Woods (25:11):
And to your point, medication adherence, access to care, care management is important for all patients, but it's especially important when we think about the Medicaid population, and they're the ones who are really going to feel most of the brunt of this whiplash, especially if it's going one direction only to go back to where you initially started.

(25:33):
Roll the tape forward for me. When everything is said and done, when we finally get out of this headache of a transition period, what will the coverage landscape ultimately look like?

Chelsea Needham (25:46):
Yeah, Rae, I think we can predict that a lot of people will go to the marketplace. So we're going to see a larger portion of people in the marketplace or on marketplace plans. We've seen projections as well, and it shows that a portion of people who are uninsured or become disenrolled from Medicaid over the next 12 to 18 months that we will see an uninsured rate that reaches about 10% by 2033. So we've seen that projection as well as a huge projection in marketplace enrollment as well.

Rae Woods (26:17):
And what does the marketplace enrollment plus where the actual Medicaid redeterminations are going to shake out? Are we going to ultimately end up back where things looked in 2019, or are things going to look quite different from that in the future?

Chelsea Needham (26:32):
I think, to your point, Rae, that there overall will be more public coverage than we've seen in previous years or years back before the pandemic occurred as well.

Rae Woods (26:43):
Which is perhaps a good reason to reinforce something that Sally said earlier, which is, the problem isn't just redeterminations. We have to think about some of those perennial challenges on making sure that we're ensuring access, that we're ensuring health literacy, that we're focused on closing care gaps, we're focused on maternal health, we're focused on all these things, because we're actually probably going to end up in a world where there's going to be more public coverage than we had back in 2019.

(27:12):
We've been talking about this drawn out process that has been Medicaid redeterminations, and the thing that I hear loud and clear from the two of you is that the work is not done. So before we close this conversation, what are the action steps that you want to see our listeners do? What are the things you want to see payers do, providers do, maybe even employers do when it comes to continuing to respond to Medicaid redeterminations?

Sally Kim (27:41):
That is a loaded question, so let me break it up by stakeholder. For providers, keep doing what you're doing. Thank you for all that you're doing to help with redeterminations this year. And in fact, a lot of plans offer grants for the work you're doing. So if you're not already receiving them, check if your plans offer those grants.

(28:00):
I would say for MCO, so Medicaid plans, like I mentioned before, the winners are really going to be the ones who take lessons from what they learned this year through redeterminations and apply them to those perennial challenges. So are you working with your providers better because of this? Are you using other non-provider folks? For example, I heard of a plan that is putting in these messages into utility bills. So working with utility companies. Is that a partnership you could continue even after we're done this huge run of redeterminations? And even improving our outreach to members. I think there's a lot we can improve with that. So are there trends that we can learn from this year?

(28:46):
Those were our Medicaid plans, but even non-Medicaid plans. So if you're in the commercial lines of business, your membership is going to change dramatically. We're already not doing the best job with outreach and with social support services that the need to improve that is going to become even greater as our membership changes. So we have to adjust our strategies accordingly.

(29:10):
And then the last stakeholder that we didn't touch on that much, but is such a big part of this are the states. I think that they are doing a lot and they're learning that they can rely on plans to help them, and hopefully they continue to feel that way in years to come. For example, allowing plans to update contact information for members in public files. I've heard some states start to do that, and that's something that plans have only dreamt about for years. So I guess to look at the silver lining through all this, there are some changes that will benefit Medicaid members in the future as well.

Chelsea Needham (29:46):
Yeah, Sally, I think you've created such a great laundry list of things that we expect to see from our stakeholders. I'm so excited to dive deeper into our Medicaid research so that we can impact what plans and states and other stakeholders can do to improve outcomes and Medicaid.

Rae Woods (30:04):
Well, it was a loaded question, but I'm actually happy that you gave our listeners a laundry list of things to do, which tells me that a lot can and should be done. So Chelsea, Sally, thank you so much for coming on Radio Advisory. What can we expect next from the two of you?

Chelsea Needham (30:22):
Thank you, Rae. We love being here with you. You can expect for us to be continuing to conduct our Medicaid research. We'll be planning to put out some additional deliverables and content related to what we've been talking about today on the podcast, but also just for tactical advice for our stakeholders and what they can be doing to improve Medicaid outcomes and what they can expect to see across the Medicaid landscape in years to come.

Rae Woods (30:49):
I love it. Well, thanks for coming on Radio Advisory.

Sally Kim (30:52):
Thank you. Thanks for having us.

Rae Woods (30:59):
Okay, okay. I know I spent a lot of that conversation talking about the messy transition period that we're in, and frankly talking about how hard it is going to be for every stakeholder and the impact that it will have on all of us, including patients. But I also hope you heard that there is a lot that every single listener to Radio Advisory can do, not just to get us through this transition period, but to make sure that we are stronger coming out of it. So remember, as always, we are here to help.

(31:39):
If you like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Kristin Myers, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston and Erin Collins. Thanks for listening.