Medicaid Changes Roiled the Nation. Health Centers Are Smoothing the Path to Care Access.

Editor’s note: This article is part of a joint editorial initiative between the National Association of Community Health Centers and Direct Relief.

Over the past year, patients who rely on Medicaid have been on a roller coaster of changing rules and requirements. More than 24 million people have been disenrolled from the public insurance program since March of 2023 — often without realizing it had happened — although many later regained their coverage.

Now, a new hurdle is emerging. People who currently have Medicaid have until the end of November to make the case that they should keep it. Documentation is daunting, and many underserved patients don’t know whether they’re eligible at all.

Health centers in the southeastern United States are working to overcome the challenges, helping patients understand the rules and navigate the process so that they don’t lose lifesaving coverage.

They’ve partnered with local governments for media announcements, opened enrollment services to non-health center patients, participated in community events, and made calls or shown up to patient appointments to talk about access to care.

A Shifting Landscape

The story behind the changes is a complicated one.

During the height of the Covid-19 pandemic, the US Centers for Medicare and Medicaid Services, or CMS, allowed continuous Medicaid enrollment for individuals and families. Even if someone wouldn’t be typically be eligible, they were allowed to continue receiving Medicaid coverage, no matter their socioeconomic status.

The end of that provisional coverage and the return of enforced eligibility standards, which began on April 1, 2023, is widely called “unwinding.”

Now, enrolled patients have until the end of November to submit documentation to determine future Medicaid status or find a new solution for healthcare coverage.

Some federally qualified health centers, whose patient bases typically include uninsured, underinsured and Medicaid-supported patients, expect a brunt financial hit as fewer people qualify for the government-funded program. Private practice physicians aren’t required to accept Medicaid patients and health centers receive a Medicaid reimbursement for certain services.

However, health centers say they’ll treat patients whether they are enrolled in Medicaid or not. Their biggest concern is the number of patients, especially those with chronic conditions, who won’t seek out medical care at all because they believe they no longer qualify for coverage.

A “Lag in Information”

In Florida, a state whose legislature has long fought against expanding access to Medicaid, health center staff fear that unwinding has made their patients more unsafe.

Sandra Algarin, outreach and marketing lead at Community Health Centers in Florida, said that without expanded access to Medicaid, patients are more likely to visit hospitals for emergency care, and refuse scheduled follow-ups and general preventative care with general practitioners at health centers because they (incorrectly) believe they can’t afford them.

Direct Relief has provided Community Health Centers in Florida with more than $700,000 in donated medication and medical supplies.

Algarin’s own family has struggled with lack of access to quality care the past year. Her mother, who has dementia, needed additional care. But while their household didn’t have the funds to pay out of pocket, they didn’t qualify for Medicaid support. Instead, Algarin had to bring her mother to work with her for months because hiring a caregiver wasn’t a possibility, she said.

Even in states where Medicaid has expanded, health center staff say it’s not enough.  

“There are absolutely still people who fall through the cracks,” said Ashley Shoemaker, of Louisville, Kentucky. “A lot of these people…are actually eligible, but they don’t know that they’re eligible or, now with the unwinding, they lost coverage. So, a lot of those are our most vulnerable populations.”

Shoemaker is the Director of Outreach and Enrollment at Family Health Centers, Inc. Kentucky expanded Medicaid through the Affordable Care Act with provisions that allow people to access a state health care plan. As of August 2024, about 1.5 million people in Kentucky are covered by Medicaid.

Direct Relief has provided Family Health Centers, Inc. with more than $100,000 in donated medication and medical supplies, ranging from treatments for heart disease and hemophilia to syringes and wound care items.

A certified Connector under the state health care plan, Shoemaker said the state took advantage of expanded access and introduced continuous coverage for children in 2023. However, she explained, people don’t necessarily know whether they qualify for coverage and may avoid making an appointment to see a physician due to a “lag in information.”

Sharing the Message

To keep people informed, FHC did a joint press conference with the Louisville mayor and makes routine appearances at local health fairs and community outings. The health center also offers an extended service: Whether or not someone is a patient there, they can walk in and receive a consultation on how the Medicaid rules apply to them.

Shoemaker said there are a lot of “happy tears,” when patients realize they can afford to visit the doctor: “A lot of people you know, they’re upset at first when they’ve lost their medical coverage…But when they find out that there is still affordable insurance available, it definitely eases some of those concerns.”

In states where Medicaid was expanded during the pandemic, health center employees are trying to find ways to share information with patients.

“The message that really gets through in our state is, ‘More Medicaid for more people,’” said Leslie Wolcott, director of communications at Roanoke Chowan Community Health Center in North Carolina. “What I tried to do is make sure that we are reconveying that message, more Medicaid for more people, [and] not complicating it. And then once people think, ‘Oh, more people qualify,’ then directing them to people that can help them put the application together and help get that [coverage].”

Direct Relief has provided Roanoke Chowan Community Health Center with more than $340,000 in requested medications and with grand funding exceeding $500,000 over the past five years.

North Carolina expanded Medicaid access in December of 2023, a few months after Medicaid unwinding was announced. Wolcott said staff contend with misinformation and “mixed messages” in their efforts to connect patients with health care coverage. The state even conducted market research to determine the best ways to communicate with the public about the issue, Wolcott said.

RCCHC patients can walk into the health center and work with staff on Medicaid forms. The health center uses the same QR code as the state to find Medicaid-related information and has a dedicated phone line for Medicaid questions.  Trained staff are also available at satellite sites to discuss Medicaid, including their school-based program and mobile unit.

Nesita Bishop, Business Office Coordinator at RCCHC, said their initial outreach included making calls to patients at home. She found that patients were closed off and unlikely to listen over a home phone call.

“I started (looking for) patients on our schedule that did not have any coverage and I would just go to that clinic on that day when they come in for their appointment,” said Bishop. “And while they’re waiting, I would just chat with them and get familiar with them. And then they were more willing to come in and talk to me,” she said.

Bishop said it’s difficult to determine whether their Medicaid numbers have increased or decreased as the unwinding period continues. However, she has noticed an uptick in women of childbearing age and single individuals who are looking for coverage.

Preventing “the Churn”

Wolcott said they’ve learned that it’s important to have staff available to work with patients on documents because it can also be an exhausting ordeal.

“It’s income-based and it’s a strange percentage of a person’s income,” she said. “And qualification is different depending on how many people are in their household. It’s all kinds of things so we don’t try to leave it up to the patients to figure out if they qualify or not.”

In the past, patients have experienced burnout contending with the annual application and the obscure financial rules that can disqualify them from the program. Wolcott said that the more patients they can prevent from the unwinding, the more likely patients are to continue preventative care.

“If you think about low-income people, you’re not always in the same job and you’re not always making the exact same amount of money,” she said. “So for Medicaid, when you get kicked off and then you’re back on you just stop trying because it’s such a hassle to get enrolled [with] a doctor again. And so one of the things expansion addresses is the churn, and more people can stay on without getting frequently kicked off.”