Protecting Members’ Medicaid Coverage Must Start Now

On the fourth of July, President Trump signed the Big Beautiful Bill into law: H.R.1, Public Law 119-21. This new federal legislation transforms America’s healthcare safety net and ushers in a new era of “Medicaid Reform” with approximately $1 trillion in spending cuts. Its major impact: an estimated 12 to 17 million Americans will lose their health insurance — approximately 5% to 7% of today’s insured population – between now and 2034. If the number is accurate and I have no reason to doubt its veracity, it saddens me that the richest country in the world does not prioritize healthcare and housing (a discussion for another day) for all Americans.

It’s important to highlight two Medicaid policy changes — stricter work requirements and more frequent redeterminations — which mean dramatic change for Medicaid members, their health plans and ultimately the entire healthcare system. According to many experts, these policy changes will be the most devastating to people who are already most at risk and face the steepest barriers, even under the current rules:

Work requirements

Under the new work requirement, able-bodied, childless adults without disabilities aged 19 to 64 must document at least 80 hours per month of work, community service, school and/or job training to maintain eligibility. Exemptions would likely apply to seniors, pregnant people, people with disabilities and/or substance-use disorders, caregivers and parents – but these exempted groups still must follow new verification requirements. States can determine their own implementation, which could include relying on complex reporting systems that require monthly verification to the Centers for Medicare and Medicaid Services (CMS). Compliance is complicated and requires that members and their caregivers are fastidious with their paperwork and recordkeeping.

Experts believe that nationwide expansion of these requirements are likely to lead to significant coverage losses, increased medical debt, and poor health outcomes — especially among low-income and marginalized populations. Fewer wellness visits, greater use of emergency departments and more hospitalizations will ultimately mean higher costs. Similar work requirements implemented in Arkansas and Georgia were confusing to enrollees and complex and costly for states to implement. These policies triggered extensive administrative churn: beneficiaries struggled with documentation, the elderly and chronically ill were disproportionately affected, and many rolled off insurance not due to noncompliance, but because of bureaucratic hurdles.  

Redeterminations

Redeterminations are the states’ determination process about whether enrollees still qualify for Medicaid based on updated information like income, household size, and residency. Proposed reforms will make redeterminations, which are now annual, occur every six months, with added data cross-checks. 

While redeterminations are designed to ensure integrity in Medicaid, experts believe increasing them from once to twice a year will heighten the risk of unnecessary coverage churn — where people cycle on and off Medicaid for reasons unrelated to their eligibility — causing treatment delays, higher emergency care usage, and administrative strain across health systems that will have to provide uncompensated care to uninsured individuals. Rural hospitals will bear the brunt of the increase in uncompensated care.

A call to community health professionals for immediate action 

As community health professionals, we must prepare for the new world of post-reform Medicaid that will be put in place over the next several years. We must use what we know to build a plan of action now so we can hit the ground running to roll out support quickly and effectively. It’s up to us to help members navigate the tremendous spike in administrative tasks in a system already burdened by soul-crushing red tape. Our role is critical not just to our members, but to their providers, their managed health care plans and other community-based organizations that support them. 

To provide this level of increased administrative support, community-based organizations must first ensure their core operations are strong, driving maximum efficiency and automation so they can scale, as needed, to meet new demand. 

Road map to support medicaid members and prevent coverage loss

The following is a roadmap that brings together a wide range of existing and new initiatives under four key goals that enable community-based organizations to take stock of their existing capabilities and coordinate across them effectively. They can build from there, as needed. 

• Goal one: To reduce coverage loss due to paperwork issues: (a) Notify members early about deadlines and required documents (b) Help complete and submit renewal forms correctly (c) Provide document support (proof of income, ID, residency) (d) Send reminders and do follow-up outreach, and (e) Support appeals if termination is incorrect.

• Goal two: To explain new requirements: (a) Explain who’s affected and what activities count — in plain language, (b) Identify and document exemptions like caregiving or disability (c) Help members track and report activities accurately (d) Connect to local job programs and volunteer opportunities, and (e)
  Provide reminders to meet ongoing reporting duties.

• Goal three: To make the system navigable: (a) Offer 1:1 help with forms, portals, and follow-up tasks (b) Assist with digital access: uploading documents, resetting passwords, navigating portals. (c) Provide translation and literacy assistance (d) Help members access related services (e.g., SNAP, housing) in parallel with Medicaid.

• Goal four: To protect against health disruptions: (a) Monitor for disenrollment and help quickly re-enroll (b) Coordinate with providers to prevent care gaps (c) Help members explore other options if they lose eligibility, (e.g., marketplace plans, community health resources and (d) Coordinate across systems by aligning with plans, agencies, and community groups to prevent churn. 

This four-goal roadmap facilitates the ability of community-based health organizations to respond to the impact of Medicaid reforms with compassion and clarity and help minimize the likely confusion and panic throughout the healthcare system. We can’t make the paperwork go away, but we can make the process more manageable. We can be ready to step up with new levels of human support and technology know-how. It will take a layered approach to ensure engagement: health plan case managers, outbound calling initiatives, and organizations that make home visits and provide one-on-one support to members must all collaborate.  

Let’s act now to help people stay covered and help them stay connected to the system, and to the care they deserve.

Photo: designer491, Getty Images

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