Stan Dorn (00:04):
There’s a lot of cynicism about, “Oh, these inequities, these problems can never be solved.” Well, America did an incredible job of erasing this critical, essential disparity between Latinos and non-Hispanic whites. One basic lesson is not to be cynical and give up, but to recognize that if we are smart and we take into account the diversity of people who live in this country, we can really accomplish a lot.

Speaker 2 (00:36):
Welcome to Hospitals in Focus from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:46):
Welcome to Hospitals in Focus. We so appreciate your listening. Good healthcare depends on good healthcare coverage, particularly for the most vulnerable. Our current focus on mitigating the social determinants of health that threaten these Americans assumes at a minimum that we can find pathways for them to good healthcare coverage that is a basic building block to good health. Thanks to the ACA and Medicaid expansion, there are a record number of Americans with health coverage. Unfortunately, those recent gains are being undercut. The ongoing Medicaid redetermination process has left tens of millions scrambling to find a new source of coverage while millions have lost it completely.

(01:36):
As things stabilize on this front somewhat, there is a new concern on the horizon as vital ACA marketplace subsidies are set to expire in 2025. Unless Congress steps in, this could increase premiums, making coverage too expensive for many, and threaten their critical link to healthcare. Joining me to talk about how we can avoid this coverage cliff is one of the issue’s most effective and impactful advocates, Stan Dorn, currently the director of Health Policy Project at UnidosUS. He also has almost 40 years of experience focusing on improving healthcare coverage for historically marginalized and disadvantaged Americans. Thanks for joining us today, Stan.

Stan Dorn (02:26):
Chip, thank you so much for having me. I’m really excited to be here.

Chip Kahn (02:29):
Stan, as I said, you’ve been at the forefront of coverage issues for, dare I say, decades. You’ve been involved at the Urban Institute, at Families USA, and now at UnidosUS. Tell us a little bit about your work at those organizations and how much progress you feel you’ve made generally.

Stan Dorn (02:50):
Yeah. Thanks, Chip. I was at the Urban Institute for 11 years. Really loved doing that work, researching strategies to get more people enrolled coverage, looking at some of the mechanics of how the marketplace was operating, looking at Medicaid expansion, and really it was great. I mean, the ACA got implemented. Chip, I think you and I met each other shortly before I started working at Urban Institute at this cross-section of hospitals, doctors, unions, consumer advocates, a quiet working group that came up with a lot of the ideas that later became the ACA. It was a great time. A lot of good stuff happened. Donald Trump got elected in 2016, and there was an assault on the ACA that was launched, and I felt like I didn’t want to be doing interesting research studying the deck chairs on the Titanic as the ship was headed towards a massive iceberg.

(03:46):
I left the world of impartial objective, non-partial research, and hopped back into the advocacy world where I had been for many years and went to work for Families USA. It was a real privilege to be part of a broad effort that helped prevent the ACA’s repeal. Hospitals federation was incredibly helpful in that effort. Other hospitals, health insurers, it was really a remarkable coming together of so many different types of people to achieve a result that very few people thought we would be able to achieve. That was amazing. And then, I stayed at Families for a while and moved over to UnidosUS, the country’s largest Latino civil rights and advocacy group a couple of years ago, because I really sensed an opportunity to be part of a civil rights voice on health coverage that I thought could be very impactful. It’s been very satisfying. In the time that I’ve been doing the work, I was able to participate in getting the children’s health insurance program started. When I was at the Children’s Defense Fund, being part of another cross-sector effort to prevent the block granting of the Medicaid program. I was fortunate to be involved in a very obscure tax credit program for laid off workers’ Trade Adjustment Assistance and then helping shape some of the provisions of the ACA. It’s been a fantastic experience working on these issues over the years.

Chip Kahn (05:06):
Well, Stan, you’ve really contributed to so much and accomplished a lot. Let’s drill down where we are today. As the audience may know, there were so many exceptions made during COVID, and one of those was to ask the states, or I guess require the states, not to re-examine those eligible for Medicaid or those coming onto Medicaid. Now that the COVID laws have lapsed, we’re into a period in which states are making re-determinations of coverage. I’m going to ask a couple of questions here. Let me just start off by you explaining in more depth what I just described. What is this whole redetermination process?

Stan Dorn (05:51):
Sometimes it’s called the great unwinding, Medicaid great unwinding. Exactly as you said, Chip, during the pandemic on a bipartisan basis, Congress said, “We’re going to provide state Medicaid programs with more money,” so they don’t have to throw people off health coverage in the middle of the most dangerous pandemic since the 19-teens. But in order to make sure that that money achieved its goals, states were forbidden from throwing people off the program unless they moved out of state or died or requested a termination of coverage. That lasted for three years, during which the Medicaid population rose by about a third as normally. Medicaid, we’ve always had a big problem with people losing coverage at the end of their eligibility period, either because they became ineligible or because they didn’t respond to the state’s request for paperwork or they got lost in the mail, they didn’t know what to do.

(06:47):
We’ve had this serious problem on an ongoing basis and it stopped for three years and the program grew. Suddenly, starting in April of 2023, states were allowed to start redetermining eligibility and ending coverage for people for the first time since March 2020. It has been a disaster. The latest figures that I’ve seen suggest that the number of people covered by Medicaid has fallen by 12 million. Just to put that in perspective, the largest three-year loss in Medicaid coverage, the largest three-year drop in Medicaid enrollment recorded in Census Bureau data was a 4 million person drop. That happened at the 1990s after we passed national welfare legislation. Two-thirds of the way through Medicaid unwinding, 12 million people. That’s the size of the drop, three times the largest three-year drop in American history. It’s really been a stunning and very problematic development.

Chip Kahn (07:47):
Millions of people have been impacted. How did it go in terms of finding other pathways for them? Particularly, as I said in my introduction, we’re talking here about the most vulnerable Americans from a healthcare standpoint, from a socioeconomic standpoint. Did they find other ways to be covered since they lost the Medicaid they did have?

Stan Dorn (08:12):
We really don’t know a solid and comprehensive answer to that question and we won’t for a little while. We know that the marketplace, the ACA exchange went up in enrollment during the year in a way that it had never done before. Normally, during the plan year, people fall off the exchange. They stop paying their premiums or for whatever reason, they terminate their coverage. This year for the first time, we saw the people enrolled in the marketplace during the year rise. A couple of million people who lost Medicaid were able to go over to the exchange and it was really a testament to what the Biden administration was able to do. I mean, they knew that the data transfers from state Medicaid programs were pretty lousy, so they just said, “You know what? We’re going to pick up the phone and we’re going to call every single person who we find out has lost Medicaid because their income went up.” It was, I think, a tremendous success in which they should take considerable pride.

(09:06):
The problem is that 70% of the people terminated for Medicaid never got an eligibility determination. They may have been eligible, but they were terminated because the state never got a response to its request for paperwork. That can happen for a million reasons. The notice goes to the wrong address because somebody’s moved, the notice is in a language the person doesn’t understand, or it’s too complicated or confusing for people to understand, or they go on the Medicaid call center and try to reach somebody and they wait literally for hours. We did this study in Florida where we found the call center there, if you were calling on the English language line, you had to wait 35, 40 minutes. If you called the Spanish language line, you had to wait, if I remember correctly, two and a half hours to reach a human being. Just incredible problems, just procedural glitches. A big part of it is the lack of paperwork follow through, and we know historically that two-thirds of the people who lose Medicaid wind up being uninsured either briefly or for prolonged periods. When we do ultimately see those uninsured numbers this coming fall, it’s going to be a pretty grim story, I’m afraid.

Chip Kahn (10:16):
Are there any next steps?

Stan Dorn (10:18):
Oh, yeah, lots of next steps. I mean, one important thing to realize is so much of this depends on what states have chosen to do. States are all over the map in terms of how well they’ve done. There are six states where Medicaid caseloads have fallen by less than 5%. There are three other states where Medicaid caseloads have fallen by more than 30%. Two-thirds of the losses of Medicaid coverage, we figure, could have been prevented if all states had done as well as the best.

(10:49):
If all states had the same level of terminations recorded by the 10 best, then instead of losing 12 million people, we would’ve lost 4 million people. We would’ve saved 8 million people. Some states have really done their best in trying to keep people covered, going the extra mile to squeeze every available data source to see if people are eligible without having to send them paperwork, and others haven’t minded to see people fall off the program. Some governors, I’m sorry to say, have even said it’s a good thing that people have lost Medicaid. There are states that are in between that have archaic computer systems, and despite the best intentions and efforts of their leadership, they’ve not been able to do what they would’ve liked to do. It’s been a very variable picture.

(11:33):
In terms of next steps, one thing we really like to see happen is to have states reach out to the millions of people who lost Medicaid because of missing paperwork, because of procedural terminations. It’s not enough just to send them a notice and say, “Hi, come on back. You can sign up for coverage.” What’s important is person-to-person assistance, helping somebody who knows the system fill out the paperwork for them, whether that’s the state Medicaid office contacting people or Medicaid managed care plans or community organizations. It’s really important we think to start reaching out to the people who’ve lost coverage because of missing paperwork and help them either get back on Medicaid or transition to a different form of coverage. That’s one thing we’d like to see happen.

Chip Kahn (12:16):
Well, we’ve learned so much since the COVID pandemic. I mean, we’ve just gone through this issue of redetermination, which was one of the side effects of going off the pandemic. But during the pandemic, the general issue of social determinants of health really came to the surface and they were populations of Americans that were more adversely affected, particularly some of those on Medicaid. Are there lessons that we learned, whether it’s treatment for those people or implications for the program in that pandemic itself? Here, I’m not so much speaking about literally the coverage issue, which we just discussed, but in the program itself, are there any kinds of adjustments that should be made or accommodations to bring in other people to eligibility who might not be eligible now, who were desperately in need of coverage during COVID?

Stan Dorn (13:13):
Boy, that’s such a great question, Chip. A couple of thoughts. One striking accomplishment during COVID that has not gotten the publicity deserves, I think, involves overcoming some of the health inequities that so many people are rightly concerned about. In terms of vaccinations, life-saving vaccinations, originally there were incredible disparities between non-Hispanic whites and Latinos, where non-Hispanic whites were much more likely to get vaccinated. There was an incredible partnership between Latino community organizations, including a lot of our partners here at UnidosUS and federal officials, where there was a direct communication line between what was happening on the ground in communities with families and federal government where folks at CDC could say, “Is this working? Is that working?” We could go straight to the local community organizations and say, “Don’t do this. Do that.” Within a year, the immunization rate for Latinos exceeded that for non-Hispanic whites. There’s a lot of cynicism about, “Oh, these inequities, these problems could never be solved.” Well, America did an incredible job of erasing this critical, essential disparity between Latinos and non-Hispanic whites. One basic lesson is not to be cynical and give up, but to recognize that if we are smart and we take into account the diversity of people who live in this country, we can really accomplish a lot.

Chip Kahn (14:43):
Let’s look beyond Medicaid and focus on the ACA marketplaces or exchanges for a moment. One of the critical advances in that coverage, which has really worked for those who have had it over the many years, over a decade now from ACA, was the increase in the subsidies. Can you talk about the impact of that and the importance of that for specific Americans who might not have previously been covered or were previously covered by Medicaid?

Stan Dorn (15:13):
Absolutely. Providing increased financial assistance for people who buy their own insurance in the marketplace has made a profound difference. The number of people who receive coverage, private coverage through marketplace plans has skyrocketed since the enhancements to the tax credits took effect. Among Latinos, enrollment more than doubled over the course of a few short years. African-Americans, same thing. Enrollment essentially doubled in just three years thanks to this assistance. Those of us who’ve been working in the field for a long time, many of us thought that a core problem with the ACA as it was originally passed was there just wasn’t enough financial help to make it affordable for low and moderate income people or older folks or people living in areas with high health insurance costs. There just wasn’t enough financial help to make it realistic that people would be able to sign up for coverage. My goodness, the improvements that have taken place these last couple of years have really taken a big bite out of that problem, and the results have been stunning.

Chip Kahn (16:16):
Well, on that coverage, unfortunately, there’s a clock that’s ticking. How do you view that clock with the subsidies expiring at the end of 2025? Why don’t you talk about that? But one of the things that I don’t think people realize is there’s a timeliness issue here as well as a deadline. Could you give us a sense of how that needs to be navigated?

Stan Dorn (16:41):
You’re touching on a really important issue, Chip. The financial assistance ends at the end of 2025 unless Congress extends it. Well, if Congress acts the way I acted when I was in college and I had things due, I would stay up till three o’clock in the morning the night before they were due and handed in… Unfortunately, that’s how we’ve seen Congress act on a lot of things. If that’s how Congress approaches this one, we are in a big world of trouble, because you can’t just turn health insurance on with the flick of a switch overnight. If Congress passes a law on December 31st, 2025, extending the assistance from 2026, well, it’s not going to work very well. Insurance companies have to prepare their bids, knowing what the rules are, starting in March of the previous year. And then they go, they submit their bids, their proposed premiums to the insurance regulator, and there’s a lot of back and forth over a three to six month period.

(17:37):
And then in November, that’s when consumers start shopping and they go online and they see what plans are available. Unless we know the level of financial assistance that people are going to get, plans can’t really prepare their bids, and certainly exchanges can’t offer plans in a way that will really be effective. What will wind up happening is that in November of 2025, unless Congress gets its act together, their constituents will all get an incredible sticker shock. Not all of them, obviously, but the ones in the exchange will go online for shopping and saying, “Oh, my goodness, look at the amount that I have to pay now,” because the exchanges will have to list the amounts without the additional financial assistance. For this to work, Congress needs to get its act in gear pretty early in 2025.

Chip Kahn (18:25):
Well, all I could say is we can hope. Knowing Congress, they definitely stay up late at night right before the deadline.

Stan Dorn (18:34):
Exactly. I should have some empathy for them. We’ve been there myself.

Chip Kahn (18:39):
But the trouble is that when it was just a grade, it was just you. Here, it’s millions of people that are impacted by their actions or lack of action. To draw it to a close, Stan, this has just been so informative, our conversation. We’ve been talking about two big things. We’ve been talking about the effect of ACA on Medicaid and bringing in so many uncovered, older, and single Americans, and then we’ve talked about, really, the tremendous expansion and wonderful coverage in the marketplace exchanges with the subsidies. Can we draw it to a close with you just talking about where you think we need to go with ACA in the long term in terms of this framework? What do we need to do to fix the law? I must add that it is encouraging that there are some states now that have been holdouts that are beginning to circle around the possibility of providing coverage. We’re still a long way even having from 50 states, all the other areas of America having coverage, but we’re getting closer. How do you see the future unfolding?

Stan Dorn (19:55):
Well, I think that one bright spot resulting from the unwinding, the great Medicaid unwinding, is that, as with so many other aspects of the pandemic, it’s drawn the country’s attention to pre-existing problems. It’s really reminded us all that when it comes to healthcare, paperwork can be fatal, paperwork can kill. That if we ask people to fill out reams of paperwork in order to get healthcare or to keep healthcare, some people will do it and some people who are overburdened and underresourced just won’t be able to. It’s not just about people losing coverage during the pandemic. As one of your questions so astutely pointed at, Chip, two-thirds of people who are uninsured today are eligible for Medicaid or financial assistance in the marketplace but not enrolled. I think we really need to learn from this experience and say, “We need to transform these programs and make them a lot more paperless,” and we know how to do this.

(20:51):
We’ve done this with other programs. You redefine eligibility so that, for example, last year’s income tax return automatically qualifies you for assistance this year. You can come in and show that your income has fallen since then, get extra help. That’s how we do it with college student aid. That’s how we did it with the Child Tax Credit. We need to do that with healthcare, too. Or to say that if you get SNAP, you automatically are eligible for Medicaid. My goodness, 97% of the people who get SNAP are eligible. Can we just get them enrolled? There’s a million details that have to be worked out as always, but that’s the direction where I think we need to head, which is simplifying the process of enrollment and retention, restructuring the program so that data matches here in the mid-21st century can be used to renew people instead of asking people to fill out pieces of paper.

(21:38):
I think we can get there. We’ve already seen great progress. I mean, some of the best states are renewing 90% of their people by data matches. Nationwide, we’ve seen a doubling in the percentage of people who are renewed automatically based on data. States like California have quickly tripled the number of people who are renewed based on data, so I think we can get there, but it’s going to take a lot of work, a lot of wonky detail scrubbing, and a lot of political will. But Chip, I’m confident with folks like the Federation of American Hospitals working on the side of people who really need help that we can get there.

Chip Kahn (22:13):
Stan, I really appreciate you taking time for our podcast today and just deeply appreciate all the work that you’ve done also on this issue. Look forward to collaborating further into the future to get more Americans the kind of healthcare they need with good healthcare coverage.

Stan Dorn (22:32):
Absolutely. Absolutely. Really a pleasure, Chip, as always.

Speaker 2 (22:38):
Thanks for listening to Hospitals in Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media at FAH Hospitals and follow Chip at Chip Kahn. Please rate, review, and subscribe to hospitals in focus. Join us next time for more in-depth conversations with healthcare leaders.

Stan Dorn – Director, Health Policy Project at UnidosUS

Since the mid-1980s, Stan Dorn has worked at the state and federal levels to improve health care access for historically marginalized and disadvantaged communities. He currently serves as Director, Health Policy Project at UnidosUS (formerly National Council of La Raza) – a role he’s held since June 2022.

He was previously Director of the National Center for Coverage Innovation at Families USA, where Dorn played a leading role in a broad range of projects, with special attention to making coverage more affordable and increasing enrollment and retention. Before joining Families USA, Dorn served as Senior Fellow at the Urban Institute’s Health Policy Center. He also was Health Division Director at the Children’s Defense Fund, Managing Attorney at the National Health Law Program’s Washington office, Senior Policy Analyst at the Economic and Social Research Institute, State Policy Director at the Alliance for Young Families in Boston, and the initial Project Director of the Health Consumer Alliance.