Nearly 600,000 children in Florida lost government health insurance last year when states began reviewing Medicaid eligibility again, according to a report published this month.
In the report, policy experts at the Center for Children and Families at Georgetown University. write that Florida is among states that prioritized "hasty" removal of kids from the program.
Officials with Florida's Department of Children & Families, which determines Medicaid eligibility in the state, strongly disputed their concerns.
The national study examines the net impacts that ending the COVID-19 public health emergency had on enrollment in Medicaid and the Children’s Health Insurance Program (CHIP), known in the state as Florida KidCare.
The federal government barred states from disenrolling people from the programs during the pandemic, but lifted that continuous coverage requirement on April 1, 2023. States began redetermining eligibility for millions of people, a process known as the “Medicaid unwinding.”
The report finds between April and December of 2023, child enrollment in Medicaid and CHIP nationally declined by more than 4 million, including 589,671 in Florida. That was the second most of any state besides Texas.
“Florida is a state that went out pretty quickly and they completed 75% of their renewal processing in 2023, so we have some states that started later and went more slowly and, generally speaking, when a state is moving quickly, it creates more pressure on the system,” said Joan Alker, executive director of the Georgetown center and the study’s lead author.
“So more people calling into the call center, more people trying to access appointments, either online or in person, more people trying to get help from community sources, etc.”
And, she suspects, more children losing Medicaid coverage who may still qualify. Since income limits for children in Medicaid are much higher than for adults, Alker said, most kids likely remain eligible for coverage.
Reducing barriers to Medicaid renewal
Procedural terminations occur when states remove people from their Medicaid rolls because something went wrong in the renewal process, not necessarily because of eligibility. A family might struggle to navigate the process or fail to respond to a renewal request, or program administrators or computer systems might make errors.
Florida’s procedural removal rate is better than most states, but data shows it’s still more than 60%.
Many individuals eventually get their coverage reinstated when the problem is addressed, but Alker notes those complications can still cause health and financial problems for families.
“Any gap in coverage for a child is problematic,” said Alker, who said while children are relatively inexpensive for health systems to cover compared to adults, they do require regular care, including checkups with pediatricians or trips to the emergency room from accidents or asthma attacks.
“A kid can fall down and break a bone on any day of the week, and it doesn’t matter if it's just two months without coverage, that’s going to incur large medical bills for that family,” said Alker, who added children with complex medical conditions are more at risk.
DCF stands behind strategy
State officials are firmly pushing back on the report and say many kids disenrolled from Medicaid have signed up for other health plans.
“Any notion that Florida has failed in this process is false,” DCF deputy chief of staff Mallory McManus wrote in an email.
Over the past 12 months, McManus said, the state has redetermined Medicaid eligibility for 4.8 million beneficiaries. Response rates have improved since before the pandemic, she said, with 90% of individuals responding when the agency reached out. A similar response rate was reported specifically for families of children with complex medical needs.
“Our outreach strategy goes above and beyond federal requirements,” said McManus, who added the state contacted some “unresponsive” families up to 13 times via phone, mail, email and text before disenrolling them and established a dedicated help line for Medicaid renewal assistance.
Florida is one of nine states that U.S. Health and Human Services Secretary Xavier Becerra wrote letters to in December expressing concern about large numbers of child removals. However, McManus notes, Florida has never been ordered by the federal government to pause renewals for not complying with unwinding requirements as with some other states.
“We haven’t just complied with all federal requirements; we have exceeded them,” she said. “It is hard to fathom what additional measures the state could even take beyond the exhaustive measures that are already in place to support these individuals through the process.”
Florida is the only state that chose not to take advantage of any of the additional policy waivers the federal government offered to help with the process.
However, some of those flexibilities involved things the state was already doing, such as using food stamp data to help identify individuals’ Medicaid eligibility.
Alker said Florida still needs to improve how it handles “ex parte renewals,” when a person’s coverage is restored automatically using existing data. This can save families a lot of stress and confusion and potentially protect people from wrongfully losing coverage, she said.
According to a separate analysis the Georgetown center maintains to track unwinding data, Florida ranks near the bottom when it comes to automatic renewals, with only 22% completed this way as of February.
“They’re just not maximizing what they can do with their eligibility systems and taking paperwork out of the process, which is really the way of the future,” said Alker, who added states with high rates of automatic renewals like North Carolina, Oregon and Arizona have had fewer declines in child enrollment.
Where are kids getting coverage?
For the nearly 600,000 kids who lost Medicaid or CHIP last year in Florida, Alker said it’s unclear what everyone’s coverage situation looks like now.
Surges in Florida KidCare and marketplace enrollment account for some of the Medicaid declines, McManus said.
“As of April 2024, more than 182,000 children have enrolled in Florida KidCare, representing a 66% increase in enrollment since May of 2023,” she said. “… Additionally, we have seen enrollment in the federal marketplace increase by 1 million consumers over the last year, including a 50% growth in the number of children under 18.”
The Georgetown center compared Medicaid child enrollment losses to data on separate CHIP enrollment growth in its report and found that the gains only offset Medicaid declines by about 10% nationally last year. In Florida, it’s closer to 12%, according to Alker.
Despite a record-high year for marketplace enrollment, those gains only offset child Medicaid and CHIP declines by about 14%, the report said.
That leaves thousands of other children in Florida unaccounted for.
Some families may have moved over to employer-sponsored health plans. Alker, however, said most people on Medicaid work in low-wage jobs and that even if they’ve started earning enough to stop qualifying for the program, it’s unlikely all of them have access to affordable employer-based plans for themselves, let alone their child dependents.
She suspects many kids are now uninsured.
“So there are many reasons to worry here; families need a source of affordable, comprehensive coverage for their children,” she said.
Florida faces a class-action lawsuit that claims the state did not properly inform people before dropping them from Medicaid during the unwinding.
The state is also suing the Biden administration to challenge a rule that requires states to keep children continuously enrolled in CHIP for a year even if their families stop paying monthly premiums.
McManus blamed that requirement for delays in implementing a Florida law that Gov. Ron DeSantis signed last year to expand Florida KidCare’s eligibility requirements from 200% to 300% of the federal poverty level, which she said could serve an additional 68,000 children.
“The Agency for Health Care Administration anticipates this unlawful mandate would cost the state approximately $1 million each month,” she wrote of the agency that administers the Medicaid program in Florida.
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