A year into the process of Medicaid unwinding, the number of Iowans who have been disenrolled has far exceeded the state's initial projection.
According to state data, at least 283,000 Iowans have been disenrolled as of March, including 87,000 children.
Last March, the Iowa Department of Health and Human Services initially projected that around 17.6% of Medicaid members, or around 150,000 Iowans, would be disenrolled under the year-long process of Medicaid unwinding, or removing people who no longer qualify for Medicaid following the end of a federal requirement that prohibited states from disenrolling anyone except in limited circumstances during the COVID-19 pandemic.
HHS officials told IPR the number of disenrollments is lower than the state figures show since they don't include the number of Iowans who have had coverage reinstated under a 90-day grace period that allows those who have incorrectly been disenrolled to have their coverage reinstated without interruption.
"If they simply just missed the paperwork and all of the following communications and show up at the pharmacy or their doctor's office and discover that they have been disenrolled, there is a fairly expedited process to get back on," said Elizabeth Matney, the director of Iowa Medicaid at the Department of Health and Human Services.
The most recent state figures show about 44,100, or 18%, of Iowans who lost their Medicaid coverage had it reinstated through November of last year.
The number of reinstatement requests and appeals under unwinding have been lower than the state anticipated, Matney said.
"That gives me some sense that we're not disenrolling individuals that wanted to stay on for Medicaid coverage," she said.
Matney said Iowa's disenrollment numbers are much higher than initially projected because the state thinks it underestimated how many Iowans had been able to obtain health insurance elsewhere, such as from an employer or through the ACA marketplace.
"What we're seeing in reality is that we have a high number of individuals that have transitioned to the marketplace," she said. "We have a high number of folks that might have been underemployed or unemployed during the public health emergency, but they are now employed again and connected with employer-sponsored insurance."
Two approaches to unwinding
There's no way for Iowa HHS to know if those who have been disenrolled from Medicaid have obtained other health insurance, Matney said.
But she said there are statistics state officials look at that can provide some insight into coverage, such as the number of reinstatements and appeals, enrollment numbers under the ACA marketplace and the number of Iowans who reported having other health insurance on top of Medicaid during the pandemic.
A recent KFF poll surveyed 1,227 adults across the U.S. who were on Medicaid prior to unwinding and found 23% of enrollees who were disenrolled remained uninsured, while 47% reported they were eventually re-enrolled in the program and 28% reported finding other insurance.
A report released this week by the nonprofit the Urban Institute and the Robert Wood Johnson Foundation found Iowa was one of eight states that exceeded initial Medicaid unwinding disenrollment projections by more than 100%. Iowa's disenrollments are at 159% of the initial projection, the third highest in the country. The national average was 61%, according to federal data available through November 2023.
Katherine Hempstead, a senior policy advisor at the Robert Wood Johnson Foundation, said states like Iowa that prioritized renewals for those who were most likely to be ineligible and took fewer federal waivers meant to help streamline renewal efforts were most likely to exceed projections.
States generally have taken two different approaches to unwinding, Hempstead said. Some prioritized getting those who were ineligible off at the risk of accidentally disenrolling people who were still eligible. While others have approached unwinding at a slower rate at the risk of continuing to pay for those who no longer qualify for or need Medicaid coverage.
"It does seem like those states that said the most important thing is to get the ineligible people off. Those were the states that had a lot of unnecessary terminations of people, especially children, who were eligible," she said.
Family and child policy experts and federal officials at the Centers for Medicare and Medicaid Services have expressed concern over the high rates children who have been disenrolled under unwinding and the effect it could have on their care, even if they are reenrolled eventually.
Hempstead said that's her primary concern about the report's numbers, but she said as there are limitations to the report's findings, as unwinding is still in process, including that figures don't reflect what reenrollment numbers are like.
“This process isn't over yet, so some of this could get sorted out," she said.
'It is in our best interest to get people covered'
In the meantime, Primary Health Care, a federally qualified health center that operates clinics in central Iowa, said the center has seen a 6% drop in the number of patients on Medicaid in the past year.
About 42% of the clinic's patients were on Medicaid as of the end of 2023, and that number continues to drop, CEO Kelly Huntsman said.
At least 4% to 5% of patients, or about 2,000 to 2,400 patients, were impacted by unwinding, she said, and the clinic's predominately low-income patients tend to change addresses frequently, presenting additional challenges when it comes to filling out required Medicaid reeligibility paperwork from Iowa HHS.
"When the state sends out the letters, sometimes they've changed addresses once or twice since then, and many of our patients are non-English speaking," Huntsman said. "Sometimes the reading level of those materials is not at a level that is easily comprehended by our patient population. So it's a challenge."
Samantha Kohls, Primary Health Care's patient services director, said many patients don't prioritize sending the paperwork back and often don't realize they are no longer on Medicaid until they show up for an appointment.
"They have other life priorities that take precedence over filling out an application or communicating back with that, and so we see a lot of delayed getting back on Medicaid if they qualify until they actually need the appointments," she said.
As a federally qualified health center, Huntsman said the clinic receives grant money to cover care for uninsured patients, but that service can stretch the clinic's budget.
"That is definitely a struggle for health centers," she said. "In general, when those patients fall off, we still see those patients and the grant money doesn't always doesn't always cover that. So it is in our best interest to get people covered."
