What 750,000 Americans signing up for ACA coverage in a single day really says about our politics

Republicans, particularly elected Republicans, pretend to care about many things. They pretend to care about the border. They pretend to care about crime. They pretend to care about “woke” teachers and professors in our public schools and universities, and they pretend to care about the type of books read by students who attend those schools and universities. They pretend to care about gender-affirming care for children they’ll never encounter, and they pretend to care about forcibly maintaining the unwanted pregnancies of people they have no interest in or respect for.

Republicans spend so much time and effort pretending to care about these things because they want to distract Americans from what it is they really don’t give a damn about. Namely, they care not about the actual health, well-being, and survival of the ordinary people they’re paid to represent, especially those who happen to be from poorer or low-income families—children in particular. 

But most of all, Republicans want to distract us to avoid the fact that Democrats actually do care about such things.

Beginning at the outset of the COVID-19 pandemic, states were prohibited, thanks to a law introduced by Democrats, from unenrolling Medicaid recipients—through regular eligibility based on family size and income—if they wanted to keep their funding. The process was called “continuous enrollment,” and according to KFF, it kept approximately 23 million Americans added to the Medicaid/Children’s Health Insurance Program rolls during that time of unprecedented economic crisis. Nearly one-third of those people were children. As of December 2022, the total Medicaid/CHIP enrollment numbers had grown to approximately 92 million. 

By law, the period of continuous enrollment ended on March 31, and the Medicaid unwinding, as it’s called, began. States began to quickly  “unwind” their Medicaid/CHIP rolls, a process that resulted in cutting millions of people off from the health coverage they’d relied on during the pandemic. According to a study by KFF, about 70% of those cut off since March were removed due to “procedural” reasons, such as failing to return paperwork to confirm their eligibility—often because they had moved.

Some states performed their unwinding process with what can most charitably be described as callous indifference. In Texas alone, as reported by the Texas Tribune, approximately 600,000 Medicaid/CHIP recipients were cut off from coverage. This severance happened not because their income had increased so much to render them ineligible, not because their children had aged out of the program, but because of “procedural” errors, including “everything from sending in applications in the mail a day late to not including the correct documentation.”

As reported by Neelam Bohra, writing in September for the Tribune:

Without access to medical care, those who rely on the state’s health insurance — mainly children, but also women who recently gave birth and disabled adults — are left in anxious limbo where one health emergency could strap them with heavy debt.

“Every parent worries about their child getting hurt or seriously ill,” said Michelle Castillo, deputy director for nonprofit Children’s Defense Fund, at a news conference this week. “That fear is magnified when your child’s Medicaid case is in limbo.”

Texas—whose Republican-dominated government has elevated disregard of its poorer citizens to an art form—was one of the worst offenders, but it’s hardly alone. A study by Georgetown University’s Center for Children and Families, updated as of last week, reports some 3 million children have been kicked off the Medicaid rolls due to individual states’ unwinding processes. Some of those children are ostensibly now covered by the health plans provided by their parents’ new employers, but as pointed out by CCF’s executive director, Joan Alker, the limitations of employer-based coverage suggests that number is not high.

Low-income families are less likely to have an offer of employer-sponsored insurance, and in particular, for family coverage.  Moreover, the discouraging news on this front, though, is that the affordability of employer based family coverage gets worse every year – with average employer based family premiums rising 7% in 2023 and workers expected to pay on average $6,575. So children are less likely to be landing here as opposed to a parent eligible for employee coverage – or parents may be paying very unaffordable premiums – not recognizing that their children still may be Medicaid eligible.

Alker notes that of those children disenrolled from Medicaid and CHIP in the past year, “Texas and Florida account for over one million of the children who have lost coverage.” As noted by the Southern Poverty Law Center, a disproportionate number of those removed from states’ Medicaid and CHIP rolls are people of color, and among those hardest hit by the unwinding are people who live in states that have not expanded Medicaid under the provisions of the Affordable Care Act.

States that have not expanded Medicaid, such as our Deep South states, will be more severely impacted by the termination of health care coverage. That’s because more people will fall into the coverage gap where their incomes are above their state’s eligibility for Medicaid, but below the poverty rate for insurance subsidies through the Affordable Care Act marketplace. Residents from Alabama, Florida, Georgia and Mississippi make up over 40% of the adults in the coverage gap nationwide. People of color make up about 60% of the coverage gap nationwide.

As reported by Jake Johnson, writing for Common Dreams, the Department of Health and Human Services under President Joe Biden recently determined that nine states—all of them led by Republican governors—were responsible for 60% of of these Medicaid and CHIP “disenrollments”: Arkansas, Florida, Georgia, Idaho, Montana, New Hampshire, Ohio, South Dakota, and Texas. 

Health and Human Services Secretary Xavier Becerra last week highlighted this strange proportion in letters addressed to each of those states’ governors, reminding them of their obligation to provide their poorest citizens with health care coverage.

The responses of some of these Republican governors, such as Arkansas’ Sarah Huckabee Sanders, were predictable: They blamed the Biden administration for not doing enough to inform them of their own responsibility. 

As reported by Noah Weiland, writing for The New York Times: 

In a post on X, Gov. Sarah Huckabee Sanders of Arkansas, a Republican whom Mr. Becerra wrote to on Monday, accused the Biden administration of having undertaken a “politically motivated PR stunt, accusing us of restricting Medicaid access.”

“That’s false. During the unwinding process mandated by federal law, the Biden admin sent letters to certain states to pause their unwinding, but Arkansas was never one of them,” she wrote.

The problem, however, is not the unwinding mandate itself, but the way it is being handled by several states.

As reported by the Western Center on Law and Poverty:

The process of reviewing all recipients’ eligibility has been anything but smooth for many Medicaid enrollees. Some are losing coverage without understanding why. Some are struggling to prove they’re still eligible. Recipients and patient advocates say Medicaid officials sent mandatory renewal forms to outdated addresses, miscalculated income levels, and offered clumsy translations of the documents. Attempting to process the cases of tens of millions of people at the same time also has exacerbated long-standing weaknesses in the bureaucratic system. Some suspect particular states have used the confusing system to discourage enrollment.

One such suspicious state? Arkansas.

“It’s not just bad, but worse than people can imagine,” said Camille Richoux, health policy director for the nonprofit Arkansas Advocates for Children and Families. “This unwinding has not been about determining who is eligible by all possible means, but how we can kick people off by all possible means.”

Texas, which this year kicked more people off the Medicaid rolls than any other state, has also been accused of disregarding its state’s poorest citizens. As Bohra reported for the Tribune: 

“The state handled this with an incredible amount of incompetence and indifference to poor people,” U.S. Rep. Lloyd Doggett, D-Austin, told The Texas Tribune. “It’s really appalling.”

As noted above, in states that have rejected Medicaid expansion under the terms of the ACA, a person kicked off  the Medicaid rolls due to their states’ negligent (or willful) disregard can result in them having no health insurance at all. However, residents of those states (such as Florida) who are ACA-eligible have signed up for it in record numbers over the past two years, thanks to increased subsidies under Biden’s 2022 Inflation Reduction Act.

Earlier this year, Margot Sanger-Katz, writing for The New York Times, noted ”particularly large increases in sign-ups in Texas, Florida, Georgia and North Carolina—states with large low-income populations that have not expanded Medicaid, suggesting the new subsidies are driving the change.”

It’s clear that the Affordable Care Act has become an absolute necessity for millions of Americans, a literal lifeline allowing them access to health care. But what’s driving ACA signups right now is the fact that so many people are losing the Medicaid coverage they had during the COVID-19 pandemic, many through these skewed disenrollments fostered disproportionately by Republican-led states.

As Weiland, again reporting for The New York Times, noted last week:

More than 15 million people have signed up for health insurance plans offered on the Affordable Care Act’s federal marketplace, a 33 percent increase compared to the same time last year, according to preliminary data released by the Biden administration on Wednesday.

Federal health officials project that more than 19 million people will enroll in 2024 coverage by the end of the current enrollment period next month. That total would include those who gain coverage through state marketplaces, continuing the record-setting pace.

[…]

On Dec. 15 — the deadline to sign up for coverage that begins on Jan. 1 — nearly 750,000 people opted for a marketplace plan on HealthCare.gov. It was the largest single-day total yet.

Cynthia Cox, director of the Program on the Affordable Care Act at KFF, told Weiland that the surge is primarily due to the unwinding of Medicaid eligibility.

So to recap: Americans had their Medicaid/CHIP coverage extended during the COVID-19 pandemic, thanks to Democrats. As the pandemic waned, many of those people had their coverage cut off, due in large part to the disregard—willful or otherwise—of Republican governors and Republican state legislatures. Those same Republican states also ensured that many of the citizens kicked off of Medicaid subsequently could not qualify for subsidies provided by the Affordable Care Act (another law passed because of Democrats), because those states petulantly refused the ACA’s Medicaid expansion. 

Meanwhile, those who were eligible for ACA health care coverage (the same coverage that the Republican Party has spent years attempting to repeal) signed up for it in record numbers, and continue to do so.

So which political party actually works for the health, well-being, and survival of American citizens and their children, and which doesn’t? 

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