Anticipating the End of Medicaid Continuous Enrollment and the Ramifications for Surgical Care

Mini Abstract:

Over 15 million low-income Americans are expected to lose Medicaid coverage as COVID-19 public health emergency protections end starting April 1, 2023. We explore the ramifications of the impending disenrollment on access to surgical care, racial equity, and financial risk protection. We then outline steps for the surgical community to protect low-income patients and the hospitals they rely on for care.

Surgical Perspective

As the COVID-19 public health emergency unwinds, an estimated 15 million low-income Americans are expected to lose Medicaid coverage.¹ With the national uninsured rate at historic lows and surgical volumes only beginning to recover, large-scale interruptions in health care coverage threaten to dismantle gains in surgical access. Under the Families First Coronavirus Response Act of 2020, states paused Medicaid terminations in exchange for federal relief funds. Over the three-year period of continuous enrollment, Medicaid grew by 33%¹ and safeguarded coverage for millions of newly unemployed workers and their families. Starting April 1, 2023, the pandemic-era protections expired under the recently passed Consolidations Appropriations Act and states resumed Medicaid eligibility redeterminations. In this Surgical Perspective, we explore the ramifications of the impending disenrollment on access to surgical care, racial equity, and financial risk protection. We then outline steps for the surgical community to protect low-income patients and the hospitals they rely on for care.

Delayed Access to Surgical Care

As hospitals continue to rebound from the pandemic backlog of postponed procedures, disruptions in insurance coverage may lead to affordability-related delays in seeking care, which could further limit timely access to surgery. Delays due to financial concerns may result in more advanced presentations, worse complications, and more emergent procedures. One need only imagine the patient who presents with acute cholecystitis following deferred elective cholecystectomy or the patient who requires lower extremity amputation following unmet chronic care needs and unfilled prescriptions. Deferred preventative cancer screenings could lead to delayed diagnosis and more advanced presentations precluding curative surgical resection. Interruptions in coverage may also limit access to post-operative recovery services such as physical therapy, post-acute care, and medications that are necessary to achieve optimal long-term recovery.

The story of timely access to surgical care under the Affordable Care Act (ACA) proves this case. Coverage gains in Medicaid expansion states were associated with more localized presentation and faster time to treatment across breast, colon, lung, and head and neck cancers.² In addition to earlier access to elective care after Medicaid expansion, increased coverage also contributed to earlier, uncomplicated disease for otherwise emergent conditions including diverticulitis without sepsis, unruptured aortic aneurysm, and peripheral artery disease without gangrene.² Taken together, these findings suggest that eroding Medicaid coverage is expected to exacerbate delays in seeking, receiving, and recovering from surgical care.

Exacerbation of Racial and Ethnic Inequities

Unraveling of pandemic-era Medicaid provisions may also widen the coverage gap and threaten to slow progress in addressing racial and ethnic inequities in both access to and outcomes for surgical care. While Medicaid expansion narrowed racial and ethnic gaps in insurance coverage, inequities in the uninsured rate persist between American Indian and Alaska Native (21%), Hispanic (19%), Black (11%), and White (7%) populations across the country.³ These gaps are more profound in states that did not expand Medicaid eligibility through the ACA, where the uninsured rate among Hispanic children is 13.7% compared to 5.9% in expansion states.³ Models of coverage transitions in the coming year predict disproportionate impacts on Hispanic and Black individuals.¹ Disparities in coverage disruptions may result from variability in states’ decisions to expand Medicaid eligibility through the ACA, overrepresentation in low-wage jobs that are less likely to offer health insurance, and state-based variation in administrative hurdles despite continued Medicaid eligibility.

Financial Strain for Patients and Safety-Net Hospitals

A recent report by the Centers for Disease Control sheds light on the success of pandemic relief policies in reducing the number of families with medical debt, from 14.0% in 2019 to 10.8% in 2021.⁴ People in Medicaid expansion states were less likely to report problems paying medical bills, supporting the contributions of continuous enrollment in protecting against financial risk.⁴

Unraveling pandemic-era provisions may exacerbate financial strain when seeking surgical care. Many newly uninsured Americans may scramble for affordable coverage and enroll in high-deductible Marketplace plans. Although private health insurance is often assumed synonymous with adequate coverage, patients enrolled in high-deductible health plans have been shown to present with more complex emergency surgical disease—suggesting that even insured patients may delay seeking care for acute surgical emergencies when faced with higher out-of-pocket spending.⁵ These findings, combined with analyses of Medicaid expansion,² suggest that affordability-related delays may result in more complex disease presentations which are more expensive for both patients and hospitals.⁵

The end of Medicaid protections will further strain safety-net hospitals that low-income patients rely on for surgical care. Faced with increased uncompensated care expenditures, facilities may reduce life-saving surgical services or permanently close, forcing patients to incur higher travel and time costs. This is especially worrisome among rural hospitals in states that did not expand Medicaid as a part of the ACA, which are already at increased risk of closure due to financial strain.

The Path Forward

Preventing the worst-case scenario impacts on those in need of surgical care requires a concerted effort among federal and state policymakers, hospitals and health systems, payers, surgeons, and the research community.

Enactment of pandemic-era Medicaid protections demonstrated the recognition that stable insurance coverage facilitates timely health care access and averts financial risks for those most vulnerable. However, protecting patients from insurance disruptions is not unprecedented. Over 20 states have adopted 12-month continuous eligibility for children⁶ and the Consolidated Appropriations Act will require all states to permanently follow this model. Yet for adults, only New York and Montana protect coverage through income fluctuations.⁶ Federal legislators should streamline processes for states to adopt continuous enrollment provisions currently afforded under Medicaid 1115 waivers⁶ and consider financial incentives to do so. Stabilizing coverage for working-age adults may ultimately offset costs through decreased administrative burdens and lower utilization of urgent and more invasive surgical care.

At the local level, health systems and states should be proactive in identifying patients at risk of uninsurance, simplify application processes, and facilitate transitions to Marketplace or employer-sponsored plans. For example, California and Rhode Island plan to automatically enroll those no longer eligible for Medicaid into Marketplace plans and cover initial premiums while Minnesota and New York provide off-ramps into subsidized plans with minimal costs.⁷ Payers can assist with member outreach to maintain enrollment as well as expand continuity-of-care plans that limit disruptions in surgical care teams during insurance transitions. At the same time, health systems should provide financial assistance to ensure access to medications and planned surgical and post-operative care during gaps in coverage.

The potential impacts of Medicaid rollbacks should spur the surgical community to engage in evidence-based advocacy to protect our patients. Surgeons should amplify calls to close the Medicaid coverage gap for low-income adults and health reforms that protect continuous coverage. The broad bipartisan support for North Carolina’s recent Medicaid expansion should galvanize the 10 remaining holdout states to re-examine opportunities for economic stability as pandemic-era federal funding comes to an end.⁸ We further urge researchers to examine the impacts of nation-wide unprecedented continuous enrollment to support data-driven policy improvements. These steps are crucial to not only ensure uninterrupted access to care but also to minimize financial strain and advance equity in surgical outcomes for all.