Melissa Harris-Perry: I'm Melissa Harris-Perry and this is The Takeaway. In late January 2020, former Secretary of Health and Human Services, Alex Azar, declared a federal public health emergency as a result of COVID-19.

Alex Azar: The actions we have taken and continued to take complement the work of China and the World Health Organization to contain the outbreak within China.

Melissa: Since then, that declaration has been renewed eight times. Eventually, it will expire. When it does, it may initiate another kind of public health crisis. According to some estimates, 15 million people, including 6 million children are at risk of losing Medicaid coverage when the public health emergency expires. That's because that's when state officials will sift through their Medicaid rolls and eliminate people who are no longer eligible under the expanded social safety net. For more on this, we're joined now by Megan Messerly, healthcare reporter for Politico. Megan, it's great to have you here.

Megan Messerly: Thanks for having me.

Melissa: Help us understand why millions might lose their Medicaid insurance.

Megan: Right, so the big issue here is that Congress, way back at the beginning of the pandemic, essentially told states that they're not allowed to kick anyone off of their Medicaid roles during the public health emergency. As a result, obviously, we saw a lot of people join Medicaid at the beginning of the pandemic when they lost their jobs or were unemployed. Essentially, anyone who's been on Medicaid for the last nearly two years has not been kicked off of Medicaid. As a result, Medicaid rolls have swelled.

The issue here is that states are staring down these millions and millions of enrollees that they need to complete redeterminations for. The issue here is that in the process of completing those redeterminations, some folks may fall through the cracks. Obviously, some people who are no longer eligible, the goal is to transition them to more appropriate forms of insurance, perhaps on state health insurance exchanges. The issue is that some eligible enrollees could also fall through the cracks and lose their insurance even though they're still eligible for Medicaid.

Melissa: Well, let's talk about eligibility for a moment, because it's not as though that line necessarily is enormously different in one's lived experience, especially given inflation. I keep thinking, basically, it's going from being abject poverty to just desperately poor.

Megan: Yes, it's a really good point. This is one of the big things that states are focusing on is that we are talking, again, like the most impoverished of the impoverished who are on Medicaid. You bring up a good point, which is that a lot of state officials are focused on, "Okay, even if these people aren't technically eligible for Medicaid anymore, they're probably eligible for a $0 premium on their state health insurance exchange," and making sure that they make that leap from Medicaid to the exchange is the issue here. Those folks may not know that coverage is available to them. They may find out that they're not eligible for Medicaid but not realize that another form of coverage is open to them for free as well.

Melissa: Now, open enrollment just closed on the state exchanges, right? I guess I'm wondering, is this something that we're looking at occurring for millions right now, or is this something that if they were removed from the Medicaid rolls that they'd have an opportunity to get into those state exchanges?

Megan: Right, they would have an opportunity. For seed exchanges, if you have a loss of coverage, that's a triggering event and you can sign up for plans on the exchange. We're not seeing this happen now because the public health emergency remains in place. It was extended recently to April 15th. The issue here is that states just don't know when that's going to end. It's making it really hard for them to plan and to start messaging to folks that, "Hey, you need to keep an eye out because you need to complete the redetermination process or you need to transition into a different form of coverage."

Melissa: This might be obvious, Megan, but what are the implications if, in fact, the public health disaster declaration ends in April and all these folks become ineligible?

Megan: The biggest concern here, states know that they're going to have to complete this work. There are a lot of states out there who are really concerned about this and trying to do as much preparations as they can to help these folks if they are no longer eligible for Medicaid. Part of the problem though is not all states are obviously going to have the same view of this process.

One of the concerns talking to Medicaid advocates is that there are going to be some states that, either for political purposes or for budgetary purposes, want to remove people from their roles as quickly as possible. The concern that these advocates expressed is that the faster people complete the redetermination process-- The Biden administration, by the way, has allowed 12 months for states to complete this process, but they don't have to take all that time.

Essentially, the faster the states go through this process, the more likely they are to lose people from their roles that probably should still be on Medicaid. It's worth stating that one of the main reasons that people lose Medicaid in addition to purely not being eligible for it is just because they don't complete the paperwork needed to do it. They just get tripped up in the system of renewing Medicaid. That's the big fear that Medicaid advocates have is that a lot of people are just going to get lost in the chaos of this transition.

Melissa: All right, that's so helpful and I don't want to miss that-- As much as for each individual person, this is a critical issue. It's also true that for the states, carrying the rolls longer is a meaningful budgetary matter, is that right?

Megan: It is, it definitely is. It's worth noting that the federal government, in exchange for telling states that they can't kick anyone off of their Medicaid rolls, also offered enhanced federal matching dollars for Medicaid. States have been given an incentive as well to keep people on their Medicaid rolls, but there's a lot of talk about the financial boost that states are getting from these enhanced federal dollars and whether that actually is more than the amount that states are spending, holding all of these people on their rolls that probably aren't eligible for Medicaid. It really is a budgetary issue for states. One of the things states are asking Congress for is they really want these federal matching funds.

They want these dollars to be titrated down over time to help them with the unwinding process so that the funds don't immediately cut off right now. The way it works is that the funds will terminate at the end of the quarter in which the public health emergency ends, which doesn't give states a lot of wiggle room with their budget. They're asking for a little bit more budgetary flexibility as they work through this process, which, again, they say, would give them more time and less pressure to actually go through this process and as a result, hopefully, help fewer people lose coverage who shouldn't be losing coverage.

Melissa: Now, you mentioned Congress, so we got to point out that if this terminates in April or May and then this process begins, you're talking about people in states beginning to get letters from the state saying, "By the way, you no longer have health insurance." Oh, just maybe 60, 90, 30, 10 days before the midterm elections. Is there some possibility that we will actually see an extension on the pure politics of this?

Megan: Yes, it's something that I think a lot of folks are keenly aware of. The Biden administration has signaled that this is a top priority for them. I talked to someone over the Centers for Medicaid and CHIP Services. He told me that this is unprecedented, the response that they have working with HHS and CMS. The coordination on this is something they haven't seen before. They're keenly aware of what could happen if the uninsured rate dramatically increases. I think that's why states are asking for some of this certainty from Congress.

Right now, again, this policy is tied to the ongoing public health emergency, but states are also looking to Congress to potentially decouple this policy from the public health emergency and set a date. You may say that could help because then they would have a firm date in mind. They could make preparations. It would help this process be a lot more smooth. As a result, hopefully, we won't see as dramatic of an increase to the uninsured rate, but that's, obviously, the biggest concern here.

Melissa: Megan Messerly is a healthcare reporter for Politico. Megan, thanks for joining us.

Megan: Thanks so much for having me.

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