Kaplan is a Senior Behavioral Designer at ideas42. She specializes in advocating for behaviorally informed policies, including those that promote access to postsecondary education, reduce inequality, and advance racial equity. She is a former staff member of the U.S. Senate Committee on Rules and Administration. Barofsky is an Associate Research Director at ideas42. His work covers the intersection between health and poverty, where the application of behavioral economics can improve wellbeing and human capital formation. His work has appeared in publications such as the Journal of Health Economics, The Lancet, and Health Affairs
Since April 2023, over 1.8 million kids have lost Medicaid health care coverage because of state administrative errors. This is one part of a massive undertaking known as “Medicaid unwinding,” whereby pandemic-era policies are being reversed. As a result, in August 2023, the Biden Administration told all states to report back on whether they are making these mistakes and, if so, to stop processing cases. Shockingly, 29 states and Washington, D.C. have since reported that they have incorrectly disenrolled children and families. (In fact, Hawaii already agreed to pause terminations of coverage until December.) These reports are alarming, but are symptoms of a larger issue: for years, children have been harmed by a hassle-filled and error-prone Medicaid enrollment and renewal process.
This problem is anything but new. In 2018, a one-year-old infant in Tennessee was airlifted to the hospital following a seizure. Emma (her name has been changed to protect her privacy) is epileptic and was prescribed anti-seizure medication to manage her condition. But a week before her hospitalization, the pharmacy denied her refill. Although Emma qualified for Tennessee's Medicaid program, the pharmacy said her coverage had been terminated. Apparently, her mother did not return a renewal packet on time. But her family never received the packet and was unaware of the requirement. This seemingly minor administrative hiccup left Emma unprotected when she had a serious seizure, hospitalizing her for two days.
Emma’s woes with Tennessee Medicaid were far from over. In 2019, Emma’s coverage was again suddenly terminated, and the pharmacy refused to refill her prescription. She was rushed to the hospital after another seizure. Emma’s mom entered a byzantine nightmare, a process seemingly designed for her to fail. She appealed Emma’s termination, but the state lost her appeal file. She spent hours completing a new application, but the state never called her back. All the while, Emma was unable to access critical appointments and medications. It’s a narrative that is all too real for many families: In 2020, after waiting hours on phone calls, completing countless forms, and worrying about Emma seizing at any moment, Emma’s mother joined a class action lawsuit against the state of Tennessee for its onerous and cruel Medicaid renewal policies.
Then COVID-19 emerged. As the nation was confronted with the unknowns of this rapidly spreading disease, Congress decided it was no longer acceptable to keep life-saving health care from eligible children and families for administrative reasons.
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The continuous coverage provision passed in March 2020 temporarily halted all Medicaid renewal processes. Suddenly, those eligible for Medicaid nationwide were guaranteed health coverage, and children like Emma had assured access to critical medication, therapy appointments, and other care. For a couple of years, her family was spared fighting with the bureaucracy to remain covered. The national uninsured rate dropped to its lowest level ever, with over 93 million covered by Medicaid, and about 8 million fewer people struggled with medical debt.
But the provision officially ended in March 2023, and states have begun requiring Medicaid renewals again. This unwinding process has been far from smooth: over 9.5 million people nationwide have already been cut off. Administrative hurdles have caused 72% of these disenrollments, and this is happening everywhere, from Texas to California to Florida to Washington DC. Many states—red and blue—are choosing to ignore the lessons learned from the past three years. Instead, they are reimposing the same flawed systems that repeatedly failed Emma. And as projected by a 2022 report by the Department of Health and Human Services, these rollbacks might mean that over 5 million children will eventually be disenrolled.
It doesn’t have to be this way. Administrative burdens—the time, money, and other effort required to access benefits and services—are a policy choice. The more complex a process is, the more likely it is that those eligible will fail. This is a well-documented feature of human behavior. Too often, policymakers purposefully impose administrative burdens to reduce benefit use, and this imposition has particularly devastating consequences for children.
While our peer nations have established automatic and free health coverage, the United States chooses to spend billions more on administrative costs in a hassle-filled health system. These choices have not paid off. Compared to our peers, we experience substantially worse health outcomes, including the highest rates of maternal mortality, infant mortality, and death from treatable conditions.
U.S. policymakers have selectively eliminated administrative burdens, but only for certain people. Those with employer-provided health insurance automatically receive a tax subsidy without the need for detailed forms, interviews, or signatures, and have their insurance renewed each year. But while this group, which is disproportionately white and higher income, can easily access this benefit, parents of children like Emma must overcome many hurdles to access life-saving health coverage. Medicaid disproportionately serves families of color (although the plurality of enrollees are white) and is notoriously hard to access. Administrative burdens are often imposed under false and racist pretenses. Indeed, administrative burdens most acutely reduce benefit access for those who need them most.
Luckily, not all states are returning to the onerous barriers to Medicaid enrollment that existed pre-pandemic. The Biden administration has allowed Oregon and Massachusetts to continuously cover children up to age six—a policy that could have protected Emma if implemented in Tennessee. Other states should follow suit, and go further, like automatically renewing coverage accurately for as many recipients as possible. Many states already collect the necessary information, but only do so for a minority of recipients. Removing government-imposed paperwork is one of many ways policymakers can help children access life-saving care.
As the unwinding process continues, children like Emma will be thrust back into a system that punishes families for experiencing poverty and punishes children who rely on health care to survive. During the pandemic, policymakers proved they could reduce administrative burdens. They can do it again, but it is critical that we act now.
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