Health Care News, Health Center State Policy

The Hurdles and Barriers to Medicaid Coverage

In February, just as the COVID-19 crisis hit the United States, a federal appeals court struck down the Trump Administration’s latest effort to enable states to impose work requirements on Medicaid recipients. At the time, advocates celebrated the outcome as validation of Medicaid’s longstanding role to improve health for vulnerable people without placing unnecessary obstacles in their way.

Now, as the COVID-19 pandemic wreaks havoc on our country’s health care system and economy, and rampant unemployment leads to increased health insurance instability, it is more important than ever to understand the process to apply for and keep benefits. What has been lost in many of these debates is a sad truth: people seeking to sign up for health insurance, and specifically Medicaid, routinely face extraordinary administrative barriers to get themselves covered.

In my previous job at the Ethiopian Community Development Council, I helped refugees and asylees apply for and renew their Medicaid coverage. Under current U.S. law, refugees and asylees are immediately eligible for Medicaid and go through the same application process as US-born residents. At what often felt like the front lines of our social safety net, I gained an intimate understanding of the complexities of and barriers to coverage.

First, any Medicaid applicant must have proof of citizenship/immigration status, a Social Security number, three years of tax returns, and pay stubs for precisely the past 30 days. These documents must be uploaded to an online Medicaid system where verification can take 6 – 10 business days. For individuals who do not speak English as a first language, for those who live in rural areas without internet access or in a mixed immigration status household, or who are differently-abled, even these initial steps can feel overwhelming. In addition to documentation, new applicants must also verify their identity with other financial documentation, which simply does not exist for many low-income people, those re-entering communities from incarceration, or refugees, and other new Americans.

For applicants who cannot enroll online, they must visit a local social services office with original identity documents in hand. This, in turn, creates a whole new set of obstacles: taking time off work, finding transportation, and paying for childcare. But for families who need health insurance coverage, this is their only option. This is also still not the end of the maze for people receiving Medicaid coverage. Beneficiaries are also required to continually update their Medicaid application with any changes, provide proof of those changes, and then reapply every 12 months. These and other administrative burdens on applicants and beneficiaries can cause thousands of people to lose coverage or not apply in the first place. The requirements for eligibility and continued coverage are similar for those applying to health insurance via the exchanges.

When Texas started conducting income checks for families with children on Medicaid, requiring families to respond to a letter within 10 days, approximately 50,000 children lost benefits. When Washington state required beneficiaries to prove eligibility twice annually, more than 40,000 people lost coverage. A national study of parents of CHIP (Children’s Health Insurance Program) disenrollees found that 40% either forgot to reenroll or did not understand the reenrollment process. If states implement work requirements, it will add yet another obstacle to an already onerous process. After work requirements took effect in Arkansas, 18,000 beneficiaries lost coverage in the first seven months.

Medicaid is a complicated program that relies on a carefully crafted partnership between states and the federal government, and it consumes a sizable amount of state and federal budgets. These dynamics matter. But in thinking about the barriers facing enrollees, it is critical to remember why Medicaid exists in the first place: to provide health coverage for our most vulnerable children and families in our community. Medicaid is the primary source of coverage and access to health care for approximately half of all health center patients. That is why, as states weigh changes to Medicaid, we must remember the already significant barriers that many Americans on Medicaid face each year and work to ensure the protection of the country’s most vital safety nets.

Read more here about how states are working to streamline Medicaid and CHIP eligibility and enrollment in light of increased applications due to COVID-19.

This blog is written with contributions from Bethany Hamilton, Susan Sumrell, and Jeremy Crandall of NACHC State Affairs.

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement number U30CS16089, Technical Assistance to Community and Migrant Health Centers and Homeless for $6,375,000.00 with 0% of the total NCA project financed with non-federal sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

1 Comment

  1. Hi, your blog was very insightful in speaking to the barriers people face in applying for and receiving Medicaid/CHIP and Marketplace coverage. As a former Enrollment Manager of 20 years in Colorado, I was also intimately aware of those challenges. Health center enrollment staff who assist with this process provide an invaluable service to patients who try to navigate this complicated process. The skill set and knowledge they possess make them an integral and sometimes unsung team within health centers. Thank you for the information in your blog.

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