Insight

A recent Health Affairs study found that Tennessee Medicaid cuts in 2005 led to a major increase in evictions, forecasting the potential effects of the current Medicaid unwinding. 

After the state halted coverage for 190,000 Medicaid beneficiaries nearly 20 years ago, Tennessee’s average annual number of evictions increased by nearly 25 percent compared to other Southern states.

Beginning last year, similar Medicaid cuts occurred on a national scale—at least 16 million people had lost Medicaid coverage as of Jan. 30, 2024. And though we won’t understand the fallout of the current unwinding for several years, it’s plausible that a massive wave of evictions similar to that in Tennessee may loom in the future. What’s more, losing healthcare coverage has been associated with a higher likelihood of emergency room visits, decreasing credit scores and worsening debt, and psychiatric hospitalization, all of which can negatively affect the economy. 

At Nava, where we strive to make government services simple, effective, and accessible to all, we’ve seen similar scenarios play out before. Major policy shifts that aren’t backed by modern, flexible, and resilient technology can negatively impact the public for decades. Such was the case when we helped rescue Healthcare.gov after its troubled launch. 

Based on our experience, we believe that human-centered technology can mitigate the effects of the unwinding by making it easier for people to recertify for Medicaid, while modern data practices can help states obtain the information they need to automatically recertify eligible beneficiaries. Time and time again, we’ve seen these strategies empower civil servants and vulnerable populations, especially in a time of crisis.

Background

The story of the unwinding begins at the beginning of the pandemic, when Congress enacted a policy provision that required states to keep people enrolled in Medicaid in order to receive enhanced federal funding. This provision contributed to a spike in Medicaid beneficiaries from 22 million people in Feb. 2020 to 94 million people in March 2023, when the unwinding began. 

Now, states are determining who is and isn’t eligible for Medicaid. Ideally, states would determine who is financially eligible through existing data sources such as state wage or tax databases, called an “ex parte” renewal. However, states have only been able to complete 60 percent of enrollment checks through ex parte renewals, forcing them to rely on a much more manual process for the remaining beneficiaries.

When states can’t conduct an ex parte renewal, they must reach out directly to people to confirm their eligibility. Then, the beneficiary must either log into their online portal or mail in documentation to confirm their eligibility. 

There’s a lot of room for error in this process, which is likely why procedural reasons account for 71 percent of people who have lost coverage. Often, procedural disenrollments occur because a state has outdated contact information for the beneficiary, or because the beneficiary doesn’t know how to renew their coverage. Maybe the beneficiary moved and has a new address (in 2020, one in ten Medicaid beneficiaries moved in-state), maybe they have limited English proficiency and struggle to understand communications, or maybe they don’t have access to reliable technology to log into their online portal. 

What states can do

It’s important to recognize that states are doing their best to recertify eligible beneficiaries, but often the odds are against them. Staffing shortages have contributed to long call center wait times and case backlogs, while outdated technology makes it difficult for states to access reliable data for ex parte renewals. 

Despite these challenges, certain states are doing a great job of recertifying eligible beneficiaries. Illinois has one of the lowest disenrollment rates, which may be due to its multi-platform outreach campaign to notify people of the unwinding. Virginia, another state with a low disenrollment rate, created a dedicated call center for people to call with questions about Medicaid renewals and applications. Maine has done everything from conducting outreach in multiple languages to encouraging people to update their contact information. Perhaps that’s why Maine has the lowest disenrollment rate as of Feb. 2024. 

Although a robust communications strategy is essential to notifying beneficiaries of the unwinding, it must be paired with flexible and human-centered technology that can streamline the enrollment process. 

Building a human-centered web application to make it easier for people to recertify

Several news outlets have reported that beneficiaries find it confusing and burdensome to renew their coverage. This confusion can contribute to longer call center wait times because more beneficiaries are trying to understand their coverage. For example, a family in Florida received conflicting information about their coverage via mail and their online portal. It took them three phone calls and six hours spent on hold to learn whether they’d keep coverage for their son with cancer. 

Building a plain language web application for people to renew their benefits could solve some of these issues and reduce call center volume, freeing up time for state agency staff to work on cases. That’s because an intuitive and easy-to-use application will help answer peoples’ questions about the status of their benefits, so they won’t need to seek updates from call centers. When building such an application, states should release prototypes in small bites to minimize risk and gather feedback through user research. 

During the pandemic, Nava worked with California’s Employment Development Department (EDD) to build a web application that let Californians confirm their status for unemployment benefits. In just six weeks, we launched an easy-to-use and secure application that helped meet unprecedented economic need for 1.1 million people. Using modern, human-centered design and research practices, we tested multiple prototypes with real people to create the best possible experience for claimants. Incorporating user feedback from the get-go ensured that our limited time was well spent. 

We also created a plain language guide to walk people through the application process and what benefits they could be eligible to receive. People who read the plain language guide had 2-4 times the rate of success filing a claim than others. 

Our work demonstrates that through agile methodology and user research, it’s feasible for states to quickly roll out a service that makes it easier for people to recertify for Medicaid. A centralized web application, shored up with a plain language guide, could help Medicaid beneficiaries understand changes in coverage and recertify for benefits while reducing burden for state agency staff. 

Additionally, it’s crucial that states build these portals with an eye toward accessibility. Currently, 15 states only offer their online Medicaid applications in English, and 24 offer English and one other language. Similarly, only 19 states provide information on how to obtain materials in large print or Braille, and 26 states provide information on how to request an ASL interpreter. To ensure accessibility for all people, states should aim to provide multilingual applications, and they should conduct accessibility testing and user testing with diverse populations throughout the development cycle.

Developing a robust communications strategy to notify people of the unwinding

Many people are losing Medicaid coverage simply because they’re unaware of the unwinding. For example, some families didn’t know they’d lose coverage until they were at the doctor. What’s more, only 38 states plan to follow up with people who do not respond to a renewal request, risking more procedural disenrollments in the remaining 13 states. By developing consistent and robust communications, states can prevent some of this confusion and thereby prevent incorrect disenrollments. 

When working with California, we wanted to make sure our communications effectively informed people how to confirm their status for unemployment benefits. We did this by conducting usability testing to understand which aspects of our communications worked and which didn’t. We also researched what people were saying on social media about the process of confirming their eligibility, which helped us tailor our recommendations for communications. 

For example, our usability testing revealed that claimants weren’t sure they could trust our application because it didn’t use the text message notifications they were familiar with. In response, we ensured the app notified people through the same text messages they knew. Sending reminder messages by text resulted in an uptick in traffic to the application and in completed certifications. 

States should conduct similar usability testing to understand how to reach the most people with their communications. Social media listening might also reveal useful insights on what parts of the renewal process people find confusing. 

Better data sharing practices can help states conduct ex parte renewals

Ex parte renewals can help reduce administrative burden for beneficiaries and state agency staff by decreasing the amount of paperwork required for a renewal. When states are empowered with reliable data, they can prevent incorrect disenrollments through ex parte renewals. But if states don’t have access to reliable data, ex parte renewals can have negative outcomes, like incorrectly disenrolling eligible children because their parents aren’t eligible. 

Data sharing—within the parameters of federal and state law—could help inform states who is or isn’t eligible for Medicaid. By prioritizing cloud-based data infrastructure and interoperability via Application Programming Interfaces (APIs), states can make data more accessible and useful. Cloud-based data infrastructure can help unlock beneficiary data that is housed in legacy systems, while APIs allow siloed technologies to communicate with one another and can help facilitate interoperability. 

We experienced the power of data sharing tools through our work helping the Centers for Disease Control and Prevention (CDC) operate and expand ReportStream, a tool that enables public health departments to quickly receive data, such as COVID-19 test results. ReportStream is an interoperable, cloud-based data pipeline, or a tool that receives, routes, transforms, and transports data. Specifically, ReportStream collects data from disease testing sites and delivers it to CDC and public health departments across the nation. By streamlining how public health departments receive data, ReportStream is making it easier for them to make decisions about the public’s well-being.

Similarly, we worked with the Centers for Medicare & Medicaid (CMS) to modernize and improve the way Medicare beneficiaries access care and coverage information. For this work, we supported the API infrastructure and data pipeline that integrated different sources for important beneficiary data, helping to produce a single location for aggregated Medicare beneficiary data. CMS’s ability to manage and utilize terabytes of data helps them execute outreach campaigns to several groups of beneficiaries. 

Though our work with CDC and CMS differs from what would be required for states to conduct ex parte renewals, it offers a blueprint for how states might access data more easily. Transferring Medicaid beneficiary data from mainframe systems to the cloud would make data more usable for states, while APIs could help different systems containing beneficiary data talk to each other. 

Expanding Medicaid’s reach to as many eligible people as possible

States and the federal government have already taken steps to mitigate the effects of the unwinding. Several states have paused procedural disenrollments and reinstated coverage until they make improvements to their ex parte renewal processes. States are also bolstering their outreach efforts to help more people find out about the unwinding. 

Organizations like The Center on Budget and Policy Priorities and Georgetown Center for Children and Families have suggested that states adopt policies to streamline eligibility and enrollment. These include increasing call center capacity, instating 12-month continuous eligibility for children, relying on data from other public benefit programs to determine eligibility factors, allowing self-attestation of residency, and giving people as long as possible to complete the re-enrollment process. 

The Federal government is also making efforts to mitigate incorrect disenrollments. In Sept. 2023, the U.S. Department of Health and Human Services (HHS) ordered reinstatement of 500,000 children and adults who lost coverage because their family members were no longer eligible. Meanwhile, CMS has released several time-limited waivers meant to ease the burden of recertifying. These waivers do everything from allowing states to renew coverage based on SNAP and/or TANF eligibility to extending the timeframe for fair hearing requests. 

Government should be applauded for these efforts, but any policy changes must be backed by flexible technology that can respond to peoples’ changing needs. Human-centered web applications can help streamline the recertification process, robust communications strategies can notify people of the unwinding, and better data sharing practices will enable states to complete more accurate ex parte renewals. These actions will help as many eligible people as possible access Medicaid, promoting a healthier and more financially secure public.