| Nearly 1 in 4 Americans are now on Medicaid — the largest population since the program was first created in 1965. But millions, or even tens of millions, could get booted from the program next year, as states restart eligibility checks after a forced hiatus. State Medicaid programs face a looming challenge.Once the nation's public health emergency ends — likely at the end of the year — states will be responsible for going through their Medicaid rolls and determining who is and isn't eligible for the health insurance program for the low income. It's normally a task states perform throughout the year, but they were banned from doing so during the pandemic, as a condition of extra federal dollars to help cover an expected surge in Medicaid enrollments. As we explained previously, states got extra money to help cover ballooning Medicaid costs, but in return they had to promise to not remove anyone from their rolls until the federal government concludes the public health emergency. All at once — probably starting in January 2022 — states will be under pressure to determine eligibility for their entire Medicaid population. Of course, some people will be appropriately removed from the rolls because they've gotten a job, a raise or more work hours, making them no longer eligible. But there will also be enrollment terminations because of out-of-date enrollee contact information or administrative error. And that's what Medicaid advocates are worried about. It's not uncommon during eligibility determinations for states to lose up to 25 percent of their enrollees, said Eliot Fishman, a Medicaid expert at the advocacy group Families USA. "If this goes poorly you could see at least 20 million or maybe more people lose coverage because of administrative problems," Fishman told me. "It's an eye-popping number, so it's clearly going to be a huge priority for states and the Biden administration," he added.  Rep. Lloyd Doggett (D-Tex.) speaks during a news conference last week about Medicaid expansion. (Win McNamee/Getty Images) | It's a challenge to keep in mind even as the Biden administration celebrates the Medicaid enrollments.Chiquita Brooks-LaSure, administrator of the Centers for Medicare and Medicaid Services, praised the safety-net program and the insurance it provided to Americans during the economic upheaval wrought by the pandemic and subsequent lockdowns. Between February 2020 through this past January, enrollment climbed by 9.7 million to reach nearly 75 million nationwide, according to a report released yesterday by CMS. That's an aggressive growth curve, which now means Medicaid insures more Americans than any other health-care program or insurer. | Larry Levitt, senior vice president at the Kaiser Family Foundation: |  | | | "Taken together, the 15 percent spike means the size of the public insurance program for low-income Americans now significantly eclipses the nearly 63 million older Americans covered last year through Medicare," my colleague Amy Goldstein writes. "Both health insurance programs date to the mid-1960s and were pillars of Lyndon B. Johnson's 'Great Society' anti-poverty strategies." "We've really seen how important Medicaid is to ensuring the overall health of our country and have seen this through the pandemic," Brooks-LaSure said. "We are seeing what a lifeline the Medicaid program is to so, so many Americans," she told Amy.  CMS Administrator Chiquita Brooks-LaSure testifies before the Senate Finance Committee in April. (Caroline Brehman/CQ Roll Call/Getty Images) | The administration hinted it's thinking about the massive, upcoming eligibility determination process.The process will be messy for states. By the time they restart eligibility checks, it will have been suspended for nearly two years. Many people on the rolls may have moved, making it hard to get in touch with them. And normally states check eligibility throughout the year; they're not equipped to check the whole population all at once. Perhaps tellingly, the administration is working on new regulations around the process, according to a list of work-in-process agency rules posted yesterday by the White House Office of Management and Budget. One of the rules is related to "streamlining the Medicaid and CHIP application, eligibility determination, enrollment and renewal processes." Fishman said the rule could beef up regulation for how much effort states must expend to get in touch with people, such as requiring them to use cellphone numbers instead of just hard-copy mail. He said officials might be "realizing if they don't really get out in front of the end of the public health emergency, they are going to lose a ton of people." Additionally, Brooks-LaSure said CMS is working to make sure states handle reviews properly."We are very focused on making sure we don't lose our gains in coverage through unnecessary hoops," she said yesterday. She stressed the effort the administration is putting forth to ensure people eligible for government health insurance or subsidies get access to it — including the marketplace plans sold on Healthcare.gov. That coverage is popular among people who earn too much to be on Medicaid but little enough that they qualify for a range of subsidies to buy private coverage. Brooks-LaSure said that in the past "a lot of people are lost between that transition" from the public insurance to Affordable Care Act health plans. "We should be getting whatever coverage they're eligible for," she said. | 
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