The upcoming November election will have a significant impact on health care nationwide. Policy proposals championed by candidates at the federal and state levels could radically change health law and policy in ways that will reverberate in 2025 and beyond. In this new blog series, the experts at NHeLP will analyze and discuss how various policies would positively or negatively impact access to care for millions of low-income people, people with disabilities, Black, Indigenous, and people of color, LGBTQI+ folks, pregnant people, and those who live at the intersection of those identities. Follow along with NHeLP through Election Day as we explore opportunities and threats to health care in the United States.
Artificial Intelligence and automated decision-making systems are a bipartisan concern and will likely be a focal point for the next administration. Project 2025 emphasizes Medicaid eligibility system upgrades to prevent fraud and abuse (pg. 467). However, Medicaid eligibility systems frequently deny coverage to eligible individuals, leading to irreversible harm for those wrongfully denied. These issues are often not identified by system audits, federal oversight, or other quality controls, but only after people who have lost their care begin appealing denials, asking questions, and seeking help from advocates. Fixing the system issues frequently costs millions of dollars, often causing harm for months. Although eligibility system issues have occurred for years, the Medicaid unwinding revealed system errors.
The Medicaid unwinding highlighted the need for improved system performance and increased oversight.
The volume of redeterminations during the unwinding is unprecedented and has highlighted many issues that should shape policy change. Currently, eligibility technology both automates policy that does not align with federal requirements and encodes system errors. These are not benign tech glitches. They result in people losing access to care.
When an issue takes time to resolve, it impacts more people for longer periods of time, and people go without needed health care. For example, a system problem in Florida kicked eligible postpartum individuals off of Medicaid. Instead of receiving 12 months of postpartum coverage, they only received 2. In addition to this recurring eligibility system glitch, Florida Medicaid enrollees alleged that the notices they received were insufficient to challenge their loss of coverage. As a result, Floridians went without care, including Lily M. who lost coverage while seven months pregnant and went without coverage when she went into preterm labor, requiring her to pay out of pocket for medications to try to stop her contractions.
In Texas, widespread issues with the Medicaid eligibility system have resulted in patients not learning they have lost coverage until they are at the point of care, pregnant individuals losing coverage weeks before their due dates, and children with disabilities losing critical home-based services. In Tennessee, eligibility system issues have contributed to erroneous coverage denials for several years. The system was initially implemented in 2019 with an array of issues identified in the AMC v. Smith case, which was decided in plaintiffs’ favor in August 2024.
Below is a non-exhaustive list of examples of recent technology issues contributing to terminations and people losing access to care:
- Online Portal Issues: In some states, online portals for Medicaid systems have file size, upload, and file transfer problems that result in people losing coverage even when they believe they provided all needed documentation for successful redetermination. Colorado had several online portal issues. Arkansas saw individuals with disabilities disproportionately impacted by a systems issue where the online portal showed that renewal forms and documents were appropriately uploaded, but they still received notices that the agency had not received necessary documents. Even though a phone call to the state agency resulted in assurance that the problem was solved, people later found out they had lost coverage through home and community-based services (HCBS) providers.
- Terminations for “Missing” Paperwork Submitted But Not Processed: Several state systems caused automatic coverage termination when redeterminations became backlogged. Although people provided all their information and paperwork on time, the information was not processed before the scheduled redetermination date. When the system lacked a decision input, it automatically terminated coverage.
- Incorrect Household Counting: Widespread issues occurred with states improperly applying federal requirements on household “counting”, resulting in children erroneously losing coverage. States’ eligibility systems incorrectly conducted automatic redeterminations at the household level instead of the individual level. Many eligible individuals lost Medicaid coverage. This especially impacted children who are eligible at higher income levels, and could often be renewed automatically, but whose parents or caregivers could not. When other household members were not able to be renewed and did not respond to a request for information, eligible children lost coverage. This problem existed prior to the unwinding, but it took the volume of people impacted during the unwinding to bring the issue to the attention of the Center for Medicare & Medicaid Services (CMS). This prompted action from CMS to raise the issue with state directors and call for pauses in procedural terminations.
- Improper Renewals for Individuals Who Formerly Received SSI: In Kentucky, the state system failed to check for all categories of Medicaid eligibility in violation of federal regulations. Instead, those who formerly had Supplemental Security Income (SSI) benefits were deemed ineligible when they no longer qualified for SSI related coverage. Despite possible eligibility under a different category, they lost Medicaid coverage. The same issue occurred in Arkansas until CMS worked with state officials to revise processes to correct the problem.
Eligibility systems issues across the country cause people to lose access to necessary health care. Many of these issues are not new, but have been highlighted by the volume of redeterminations during the unwinding. They will not go away on their own. CMS needs to provide more oversight of states, and states need stronger oversight of contractors to identify, mitigate, and prevent these harms. The next administration must focus eligibility system upgrades on improving access to Medicaid for eligible individuals, rather than preventing lesser threats of fraud and abuse.
