By Suzanne Wikle 

As many as 15 million people could lose Medicaid coverage in 2022 after the Public Health Emergency (PHE) declared by the U.S. Department of Health and Human Services in response to the COVID-19 pandemic ends. Congress has the opportunity now through the Build Back Better package to decrease the number of people who will become uninsured in 2022.  

In response to the COVID-19 pandemic, Congress increased federal funds to state Medicaid programs. In exchange for those additional dollars, states agreed to a Maintenance of Effort (MOE) requirement that precludes them from disenrolling people from Medicaid (with very limited exceptions) until the end of the PHE, which is expected in 2022—possibly as early as January.    

People will lose Medicaid coverage for a variety of reasons. Some will be ineligible due to income increases but should qualify for subsidized coverage through the Affordable Care Act’s marketplace. Unfortunately, others who lose coverage when the MOE requirement ends will not be eligible for other affordable coverage and will likely become uninsured unless Congress acts. These populations include: 

• Adults with increased income—but not increased enough to qualify for subsidized marketplace coverage. These adults will be concentrated in the 12 states that have not expanded Medicaid.  
• Young adults who enrolled in Medicaid under child eligibility rules and are now ineligible as adults because their state has not expanded Medicaid. 
• Parents with very low incomes who no longer have dependent children (typically due to their children turning 19 during the PHE) and whose states have not expanded Medicaid. 
• People who were insured by Medicaid during pregnancy and gave birth more than 60 days ago if their state has not extended post-partum coverage or expanded Medicaid.  

The common factor across populations at risk of becoming uninsured is clear: the lack of Medicaid expansion in the 12 hold-out states is the problem. A solution to the coverage gap in the Build Back Better package will ensure the populations above will have access to affordable health insurance at the end of the MOE requirement. A coverage gap solution is the only item in the Build Back Better discussions that is targeted exclusively at people with very low incomes. 

A coverage gap solution will also provide affordable health insurance – in many instances for the first time in peoples’ lives – to the 2.2 million people who are currently in the coverage gap. 97 percent of people in the coverage gap live in the South, 59 percent are people of color, and 100 percent of them are missing out on the benefits of the Affordable Care Act. 

In addition to a coverage gap solution, the inclusion in Build Back Better of 12-month continuous eligibility in Medicaid and the Children’s Health Insurance Program (CHIP) for kids, along with a requirement that states provide 12 months of post-partum care, will also help keep people insured.  If the post-partum extension remains a state option, people in the states that have not expanded Medicaid are at high risk of missing out again due to state inaction. 

It’s time to move the conversation beyond what is fair or not for a state that has done the right thing by expanding Medicaid. We must instead focus on the fairness to people. What state a person wakes up in each day should not determine whether or not they have access to affordable health insurance. Everyone deserves affordable health care, regardless of where they live.