By Suzanne Wikle
With the end of pandemic-era protections for people insured by Medicaid, we’re learning more about states’ outcomes for Medicaid renewals. Since states were barred from disenrolling virtually any Medicaid recipient for over three years, enrollment reached record highs and the rate of people lacking health insurance hit record lows. But as of April 2023, states were allowed to disenroll people who either didn’t complete the renewal process or were no longer eligible. Currently, more than 6 million people have lost Medicaid coverage, and that number will increase.
The disenrollment fallout is tragic on a personal level; on a systemic level, it is both enlightening and highly concerning. Requirements for states to submit certain renewal data to the Centers for Medicare and Medicaid Services (CMS) and CMS’s hypervigilance in monitoring state performance have put a spotlight on Medicaid renewals, illuminating issues that either go against the spirit of the law or outwardly violate it. CMS issued a document in July that outlined areas of noncompliance for each state, but many of these problems have likely been happening for nearly a decade—ever since Affordable Care Act rules updated state requirements for Medicaid application and renewal processes. Examples include:
Non-compliant renewal pathways.
Regulations require that people be able to submit renewals in person, by mail, via phone, or online. Not all states are complying with either the letter or spirit of this law. Twenty states have a mitigation plan with CMS to enhance the availability and accessibility of renewal pathways. Mississippi didn’t offer an online pathway for renewals, and only when pushed by CMS with unwinding did the state provide an online option, albeit one that is a stopgap measure. Several states were not attempting ex parte renewals for elderly and disabled populations as required. And while other states may technically offer all four pathways, they have unnecessary barriers. Some require an appointment for a telephonic renewal or don’t allow telephonic signatures, so people still must receive a mailed form, sign it, and return it. Prior to unwinding, Texas didn’t mail renewal forms to people; rather, it mailed letters directing people to find renewal forms through Texas’s online portal.
Incorrect ex parte process.
The first step for all Medicaid renewals is an attempt by the state to renew cases ex parte. States must use existing data to see if an individual is still eligible, and if so, renew that person’s Medicaid without any action needed by the individual. During the unwinding process it became apparent that some states are renewing entire households at once via ex parte, rather than individuals. Although this may seem like just a technical issue, this error results in people – primarily children – losing coverage because income eligibility limits for children are often higher than for adults. In those instances, children should be automatically renewed even if their parent(s) need to complete a paper renewal form. On August 30, CMS issued a letter to states outlining this issue and providing states with four options to come into compliance. As a result, 30 states reported conducting ex parte reviews incorrectly, and CMS is therefore requiring that 500,000 people have their Medicaid coverage reinstated. In addition to the household/individual issue, unwinding data has shown that ex parte rates vary widely across states, with some reporting fewer than 15 percent of cases renewed ex parte. It’s critical to understand what’s holding certain states back from more ex parte success to reduce administrative burdens and make the renewal process more equitable across states.
Improper coverage terminations.
States are required to give at least 10 days’ notice before disenrolling someone from Medicaid and may not disenroll anyone while completed renewal paperwork is pending with the state. Advocates in multiple states have reported hearing about people being disenrolled without receiving any notices, without ever receiving renewal paperwork, or after paperwork has been returned to the state but not processed. Kansas temporarily halted disenrollments due to mail delays contributing to improper disenrollments and changed its renewal timelines to come into compliance.
What’s next?
Now that these shortcomings have been identified, advocates, state agencies, and CMS must do better. Advocates are now able to see how many people are successfully renewed, how many renewals are done ex parte, and how many people are disenrolled, including for procedural reasons. Although the data isn’t perfect—for example, only a few states included racial, ethnic, or age breakdowns—it provides enough information to see where states need to examine their policies and practices to retain more eligible people in Medicaid.
While the magnitude of the task of “unwinding” from the pandemic-era continuous coverage provision may account for some poor outcomes, the reality is that many of these are systemic issues that will persist if not corrected. This includes ensuring that eligibility systems are properly programmed to follow policy and law; that notices are clear and available in multiple languages; and that state agencies and call centers are adequately staffed.
As the body that oversees Medicaid in states, CMS will play a critical role going forward. Its ability to hold states accountable through measures like pausing terminations or reducing federal Medicaid payments is mostly time-limited during the unwinding process. But CMS can do more to clarify policy, which will help state agencies and advocates know where to look for solutions. An example of this can be found in the individual-versus-household ex parte renewal process mentioned earlier. Laying out clear expectations that states must follow for this process would help minimize disruption and harm. More ex parte guidance about the acceptable age of data used in the process, how to handle people enrolled in multiple benefit programs, and outlining expectations for people who are elderly and disabled are needed. CMS can also push for continued data reporting and transparency after unwinding ends, continued state flexibilities during unwinding, and continued monitoring of states, as well as provide technical assistance as needed.
The Medicaid unwinding process shows how important Medicaid is for tens of millions of people and creates a roadmap for improving the program. It’s up to all of us to make sure the spotlight on Medicaid doesn’t fade away before systemic issues are fixed.
By Shira Small
Rising child care costs are a significant barrier to access, particularly for families with low incomes who spend the highest percentage of their income on care. Some families with low incomes can access assistance through the Child Care and Development Fund (CCDF), but this program only reaches one in six eligible children due to significant underfunding. Barriers to access are exacerbated for families of color who are even less likely to access care despite eligibility. When families do receive child care assistance, many of them must still pay a portion of the cost, otherwise known as a copayment. Copayment scales vary from state to state and are influenced by income level, family size, and other factors. However, a history of underinvestment in child care results in low wages and lack of other support for providers which can make copayments complex and unaffordable for families.
COVID-19 child care relief funding and related waiver authority allowed many states to temporarily waive family copayments, but this authority and funding is set to expire soon. The first round of American Rescue Plan Act (ARPA) child care relief funding will expire on September 30th and the remaining funds will expire in September 2024. Some states have tried to maintain copayment waivers and affordability for families in advance of the funding cliff; California is establishing a no-fee approach for families earning under 75 percent of the State Median Income (SMI) starting on October 1, 2023, and a generous scale for families earning above 75 percent SMI. However, not all states have the budget, resources, or political will necessary to modify their copayment scales to best meet parents’ needs.
The Department of Health and Human Services (HHS) is trying to help, and recently released a notice of proposed rulemaking (NPRM) aimed at addressing some of these challenges by improving child care accessibility and affordability. The NPRM requires that copayments are capped at 7 percent of a family’s income and recommends that states waive copayments for families with incomes up to 150 percent of the Federal Poverty Level (FPL) and for families with a child with a disability. CLASP has highlighted this significant positive step in our recent comments.
The NPRM also calls for Lead Agencies, the departments in each state that administer child care, to post more information about copayment scales. Lead Agencies should use simple, concise language that is accessible to all families, including those with limited literacy and those who speak a language other than English. We recommend that states share a clear definition of copayments, how they are calculated, how frequently copayments must be paid, and how parents and providers were engaged in the process for determining the copayment and sliding fee scale.
Though many states will need to wait until their next legislative session to modify their copayment scale, there are other changes Lead Agencies can make now to help ensure families understand and afford the cost of care. Lead Agencies can clarify different factors that affect copayment, such as household size; whether families pay weekly, monthly, or per child; and other variables. Doing so would help make the copayment scale more transparent and easier to navigate.
A historic lack of investment in child care has created the conditions for an inaccessible and unaffordable child care system, rooted in the devaluation of women’s and especially Black women’s labor in the child care workforce. Without adequate funding, states are forced to make difficult decisions that often result in policies that don’t work well for parents — policies like higher copayments and restrictive eligibility criteria, which lead to far too few eligible families receiving care. Copayments must be more affordable and the system must be clearer to help families access child care, but this is only possible with increased and sustained public investment.
By Rob Garver, VOA News
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Elizabeth Lower-Basch, deputy executive director for policy at the Center for Law and Social Policy, described the figures released this week as “not surprising, but deeply disappointing.”
She stressed that the poverty levels in the U.S. are very much dependent on policy choices made in Washington.
During the pandemic, “we made a decision that we were going to take poverty, and particularly child poverty, seriously, and make sure that people have what they need,” she told VOA. “That’s cash assistance, but also food benefits and health care. Now, we’re really rolling back that support, and with child poverty, we’re back where we were.”
By Catherine Rampell, Washington Post
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Most impressive: The child poverty rate, as measured after benefits and taxes, was cut nearly in half, to 5.2 percent. This represented its lowest level on record, an achievement possible partly thanks to other federal investments in kids that predated the pandemic. Such measures have been motivated by all we’ve learned about the enduring effects poverty has on kids’ development and future health, educational and career outcomes.
In this GLR Learning Tuesdays webinar, co-sponsored by Early Learning Nation Magazine, we heard a riveting conversation about early childhood policy — past, present and future.
Moderator Michelle Kang of NAEYC opened the session by recognizing the essential yet currently undervalued and undercompensated role that child care and education professionals have, and by a brief explanation of “how we got here.” Following this introduction, Kang was joined by Elliot Haspel of Capita and Katharine Stevens of Center on Child and Family Policy who reflected on Build Back Better, applauding its attempts to inject highly needed funding and create access to high-quality child care. Both, however, agreed that BBB did not sufficiently support pluralism and parent choice in terms of what kind of child care families have access to.
“Child care is locked by its economic fundamentals. You can nibble on the edges with regulation. You can nibble on the edges with some of these economies of scale, but ultimately it’s a human-intensive service to provide, and it should be a human-intensive service to provide. It’s going to be expensive.” – Elliot Haspel, Capita
Next, Stephanie Schmit of Center for Law and Social Policy shared insights into the behind-the-scenes process of getting BBB introduced, outlining some of the limitations and challenges posed by the “uncharted territory” of such large-scale child care legislation, the mindset shifts that come along with that, and what was learned to improve future legislative attempts.
We then heard from Laura Valle-Gutierrez of The Century Foundation about the very real impact that the end of pandemic rescue funding will have on families, children, child care providers and early childhood professionals, the majority of the latter being women of color. She was followed by Jessica Sager of All Our Kin who reminded everyone on the webinar of the following:
“What we are hearing from educators is this: For a moment, during the pandemic we were seen and recognized as essential workers. And now conditions have not essentially changed. And yet the funding that made it possible for us to do this work is going away. It feels like we and the children and families in our care have been abandoned…every family child care program is a community resource. It’s a hub. Sometimes it served generations of families, and when that program is gone, it is going to take decades to replace it. So the harm that we are doing to children, families and the economy in both the short term and the long term really cannot be overstated.”
Lisa Roy of the Colorado Department of Early Childhood echoed Sager’s sentiment, stating that the business community needs to get involved in recognizing and advocating for the benefits of robust early childhood systems, in addition to sharing the work that Colorado is doing in this sector.
The conversation ended with a discussion of future policy priorities to work toward a real early childhood system, the common threads of which were that the current system is not working, we need large-scale funding, and families need access to high-quality choices for their child care needs.
Washington, D.C., September 12, 2023—Today’s U.S. Census Bureau report shows—once again—that poverty in the United States is a policy choice. According to the Supplemental Poverty Measure (SPM), the overall rate of poverty in 2022 was 12.4 percent, markedly increasing from 7.8 percent in 2021, even as both total employment and full-time, year-round employment rose. And the child poverty rate as measured by the SPM more than doubled, from 5.2 percent in 2021 to 12.4 in 2022, the largest one-year increase on record—following the largest one-year decrease on record in 2021. While the SPM poverty rate grew for all groups of children, Black and Hispanic children continued to experience disproportionately high poverty rates, 17.8 percent and 19.5 percent respectively, compared to 7.2 percent for non-Hispanic white children. Non-citizens also experienced disproportionately high poverty, with an SPM poverty rate more than twice the native-born population (24.4 percent vs. 11.2 percent).
Poverty rates are affected far more by decisions made in Washington D.C., and in state capitals than any decisions made by families and communities. In fact, the primary factors contributing to U.S. poverty rates are policies that create or reinforce structural and systemic challenges like structural racism and patriarchy, enhance or undermine worker power, strengthen or weaken the social protection system, and generally ensure a strong economy that delivers widespread prosperity.
The historic decline in child poverty two years ago was the result of COVID-era policies, including an expanded, enhanced, and more equitable Child Tax Credit (CTC) and other federal programs to support people with low incomes, particularly children. Yet policymakers decided not to extend the enhanced CTC, turning their backs on children by rejecting a proven tool to fight poverty that offered Americans a return of more than $9 on each dollar of investment in families experiencing the lowest incomes. And 18 states prematurely ended SNAP emergency allotments despite elevated food prices last year, declining millions of federal dollars in nutritional support.
“Too much is at stake in both the lives of children and families, and the health of our communities for politicians to do nothing or even actively undermine them. Mountains of research make unequivocally clear that poverty hurts children, youth, and families, while also holding back the U.S. economy,” said Indivar Dutta-Gupta, president and executive director of the Center for Law and Social Policy (CLASP).
Parents with low incomes work hard every day to meet their children’s material and developmental needs. Poverty acts as a weight, pulling them back and making it harder—sometimes impossible—to overcome common challenges and setbacks. As a result, children growing up in poverty are at higher risk of developmental delays, behavioral challenges, and a lack of school readiness. First and foremost, all children deserve an opportunity to meet their highest potential. But the costs of not addressing child poverty aren’t just felt by the children themselves. One study estimates that child poverty costs the U.S. economy just over $1 trillion per year, or 5.4 percent of GDP.
Abundant evidence demonstrates that income support programs can improve the rates of child poverty. Cash supports for families lead to better birth outcomes, greater educational attainment, and improved overall health. Research also shows that this assistance reduces child welfare system involvement, lowering the risk of children being separated from their families. “As the expanded CTC revealed in 2021, we have the tools to end child poverty in this country. We just need the political will to use them,” said Dutta-Gupta.
The Census report also found that the share of people without health insurance in 2022 dropped by 0.4 percent to 7.9 percent, tying the previous low. This also reflects a policy choice to establish the continuous coverage provision under Medicaid that began in 2020. Unfortunately, this provision ended in 2023, and we know that at least 5.9 million people, including many children, have already lost Medicaid coverage. When we see the 2023 figures, the uninsurance rate will likely be much higher. We need a permanent system offering affordable, continuous health insurance coverage to all, without forcing people to navigate a paperwork maze to keep their coverage. Continuous coverage reduces administrative burden and prevents delays and gaps in treatment that can lead to worse health outcomes.
Congress has an outsized role in reversing the country’s increased poverty. And September is a pivotal time, as Congress must pass bills by the end of the month to fund the continued operation of the federal government. This is an opportunity for policymakers to provide adequate funding to fight poverty and promote well-being, free of harmful “riders.” This includes addressing the child care funding cliff threatening families and our economy, passing a Farm Bill that improves SNAP and makes it more equitable, and enacting a CTC that’s paid to families regardless of their specific federal income tax liability and that applies to families without regard to immigration status.
Alycia Hardy, Alyssa Fortner, and Tiffany Ferrette presented to the NC Coalition for Inclusion, Not Expulsions on their brief “Centering Black Families: Equitable Discipline through Improved Data Policies in Child Care” and state and federal recommendations to address harsh disciplinary practices.
By Sakshi Udavant, Prism
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Texas is home to one of the nation’s largest Latinx populations and the largest population of Latinx people impacted by abortion bans, with 2.9 million Latinx people of reproductive age affected. This demographic largely comprises immigrants, with The National Latina Institute for Reproductive Justice’s fact sheet in partnership with The Center for Law and Social Policy showing that 39% percent of all Latinas living in the 26 states that have banned or are likely to ban abortion following the 2022 Supreme Court Dobbs decision were born outside of the U.S.
The COVID-19 pandemic led to a crushing recession that threw millions of workers into joblessness. Unemployment rose higher in three months of COVID-19 than it did in two years of the Great Recession. However, driven by historic public investments, the economy has rebounded faster and more equitably than many anticipated. The U.S. labor market recovered all the jobs lost during the pandemic recession, in just over two years – a feat that took more than six years to reach following the Great Recession. Additionally, workers’ real wages have begun to grow after a bout of high inflation, and Black workers have seen the lowest unemployment rate on record.
Watch the full recording below:
By Peter Coy, The New York Times
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I interviewed Indi Dutta-Gupta, the executive director of the Center for Law and Social Policy, who worked on the National Academies report. He and his colleague, Elizabeth Lower-Basch, have a brief and positive take on the report. One thing Dutta-Gupta pointed out is that whatever the Census Bureau decides to call the poverty line has no direct impact on spending to fight poverty. That’s up to Congress.
Dutta-Gupta also said that in the debate over absolute versus relative measures of poverty, he’s in the relative camp.
“The whole concept of poverty is specific to a place and time,” he said. “Societies do have expectations and norms.”