How 'unwinding' cost more than 200,000 Iowans their Medicaid coverage

More than 200,000 Iowans removed from Medicaid during the state’s eligibility review lost coverage for incorrectly filling out paperwork, failing to respond to the state or other procedural reasons.

In some cases, those Iowans didn’t realize they needed to re-enroll for coverage under the state insurance program.

As a result, local health officials at Broadlawns Medical Center say they often meet patients who don't realize they lost their coverage until they're admitted for a hospital stay or are trying to refill a prescription.

“Unfortunately, most patients do not know that they've been dropped off Medicaid until they're not feeling well," said Tira Mays, government programs coordinator at Broadlawns.

Over the past year, state officials have been reviewing thousands of Iowans' health coverage under the safety net insurance program following the end of the national public health emergency declared during the pandemic. During that period, it was guaranteed that no one would lose Medicaid coverage.

Starting April 1, 2023, state officials have been reviewing the qualifications of more than 890,000 Iowans who were enrolled in state programs, including traditional Medicaid and CHIP (the Children's Health Insurance Program).

Those who still qualify have the opportunity to re-enroll for coverage. Those who are no longer eligible are discontinued.

Since the state began this "unwinding process," nearly 550,000 Iowans have been re-enrolled in Medicaid coverage, according to the latest data available from the Iowa Department of Health and Human Services. Fifty-one percent of those renewals were done automatically based on information the state has on the enrollee through a process called "ex parte renewals."

But more than 282,000 Iowans have been kicked off Medicaid coverage.

Of those, about 74% — or more than 209,000 — were disenrolled because of "procedural reasons," such as failing to correctly fill out and return state paperwork.

The remaining 26%, about 73,500 individuals, were deemed ineligible.

"The COVID-19 pandemic brought about unprecedented circumstances, with no point of reference of what to expect for the continuous coverage unwind," said Alex Murphy, communications director for Iowa HHS.

Murphy said "disenrollments" were proportionally high initially, but "Iowa anticipated the standard ‘churn’ that happens in Medicaid enrollment based on the annual renewal cycles."

Yet that coverage gap raises concerns for doctors about patients' disrupted health care. It's particularly a concern for patients with chronic medical conditions such as heart failure and diabetes, especially if doctors aren't aware they aren't able to afford their medications because of insurance issues.

“People feel like they’re getting the rug pulled out from under them if they don’t understand what’s happening, and there can be a sense of shame with people who suddenly have to acknowledge they don’t have coverage," said Dr. Jason Kruse, internal medicine physician and interim chief executive officer for Broadlawns. "Getting past that to hook them up with care is a barrier.”

How has Medicaid unwinding affected Iowa's total enrollment?

In early 2023, state officials projected about 17% of total enrollees in Iowa would be disenrolled from coverage throughout the Medicaid redetermination process, or more than 150,000 individuals.

Iowa is currently seeing a net disenrollment of 18% to 19%, according to HHS.

Iowa does provide a 90-day grace period for members whose Medicaid coverage was discontinued for a procedural reason, to try to ensure they don't have a coverage lapse.

Currently, state officials are seeing a 25% to 30% re-enrollment among those individuals within that three-month time period, Murphy said.

Iowa's rate of procedural disenrollments is on par with the national average, according to Louise Norris, health policy analyst for healthinsurance.org. So far, about 69% of all disenrollments across the country have been procedural.

The rate of those disenrollments also changed throughout the course of the unwinding period, Norris said. In April 2023, Iowa had roughly 30,000 procedural disenrollments. By December, the number had dropped to 4,800.

That adjustment came after the U.S. Centers for Medicare and Medicaid Services sent a letter to Iowa and other states warning them that an issue with their renewal process may have been inappropriately kicking off eligible individuals.

Overall, Iowa's total Medicaid enrollment has dropped about 19%, which Norris said puts Iowa at one of the highest declines in net enrollment nationwide. Only 11 other states have a higher total percentage decline in Medicaid enrollment, she said.

As of March, Iowa had more than 725,000 members enrolled in a state Medicaid program, according to HHS.

Why are procedural disenrollments concerning?

Norris said procedural disenrollments can be intentional, with the individual choosing not to participate in Medicaid renewal because they no longer need that coverage.

However, that's not true for everyone, Norris said. Some people get too busy and miss a deadline to fill out their re-enrollment paperwork, she said.

Others may be homeless and may not have received a renewal packet from the state.

It's unclear whether Iowans affected by the unwinding process have ended up back on some health insurance coverage, Norris said.

Anne Discher, executive director of Common Good Iowa, which advocates for children and families, said, “We've tossed a lot of folks off of Medicaid, and I think there's reason to be concerned about how they're getting health care needs met."

State officials say among adult Iowans who were disenrolled for procedural reasons, about 3% are on Medicare and another 35% have some type of major medical coverage. Among children, 28% have major medical coverage.

More than 28,000 Iowans who previously had Medicaid had enrolled in a plan through the Affordable Care Act Marketplace as of December 2023, the most recent data available, according to healthinsurance.org.

However, about 62% of adults and 72% of children in Iowa disenrolled for procedural reasons have no other known health care coverage, HHS officials say.

That raises concerns among some advocates that Iowans may be without insurance. One survey from KFF, the national research organization that focuses on health policy, estimated about 23% of U.S. adults who were disnenrolled from Medicaid during the unwinding period are now uninsured.

Eligibility thresholds for children are much higher than adults, but there isn't clear data on how many kids are making their way to CHIP or Hawki, a health plan for low-income children in Iowa.

That concerns advocates like Discher, who said children may miss developmental screenings and other critical doctor appointments if they lose health care coverage.

"That’s stuff you really would expect to go by the wayside if there’s no insurance," she said.

What's next for Medicaid unwinding in Iowa?

March 2024 marked the last renewal month for Iowa's continuous coverage unwind, but Murphy said processing "may continue for several more months."

Because of delays in federal data, Norris said it may take months before analysts have the full picture of how unwinding went in Iowa and across the country. That includes information on how many individuals may have ended up uninsured because of the process.

The post-pandemic Medicaid redetermination process has brought attention to how complex insurance can be for everyday Iowans to navigate, said Mays, who is among the financial counselors at Broadlawns who help with the health care insurance enrollment process.

If those bureaucratic aspects can't be simplified, Kruse said insurance companies and health care facilities should better staff their service departments to help patients navigate that process.

If individuals have been disenrolled from Medicaid coverage or otherwise need help getting insurance, Mays encouraged patients to reach out to obtain financial counseling through their health care provider.

Michaela Ramm covers health care for the Des Moines Register. She can be reached at mramm@registermedia.com, at (319) 339-7354 or on Twitter at @Michaela_Ramm.

This article originally appeared on Des Moines Register: How many Iowans lost Medicaid coverage during 'unwinding' period?