Colorado's Medicaid rolls are essentially back to where they were pre-pandemic after a year of removing people who were no longer eligible or didn't complete their paperwork, and health care providers say they're still struggling with the rebound in uninsured patients — some of whom don't know they lack coverage.
The department that runs Medicaid in Colorado promised it would continue trying to improve the process of determining who qualifies for health insurance through the program. The one-year "unwinding" period following the COVID-19 public health emergency ended in April, but the state will have to decide on most members' eligibility every year.
As of July, Colorado's Medicaid program covered about 1.26 million people, compared to 1.22 million in July 2019. States couldn't disenroll people from Medicaid for roughly three years because of the public health emergency, and enrollment in the state peaked at 1.81 million in May 2023, as the unwinding was starting.
Colorado kept about 55% of people enrolled during the unwinding period, which was within a few percentage points of pre-pandemic averages, said Kim Bimestefer, executive director of the Colorado Department of Health Care Policy and Financing, which runs the state's Medicaid program.
A higher percentage of people lost coverage because they didn't complete the paperwork, and a smaller share has returned to Medicaid than did in 2018 and 2019, she said during a webinar the department hosted last week.
Colorado doesn't yet have full data on what happened to the people who lost coverage, though a survey found people who were no longer on Medicaid were more likely to report they were uninsured than that they had any other particular type of coverage.
About one in four people in Colorado who lost Medicaid coverage and answered questions about it didn't know they no longer had insurance, said Emily Johnson, managing director of research, evaluation and convening at the Colorado Health Institute, which conducted the survey.
The sample wasn't representative of the overall population who had Medicaid, so the share of people who didn't know they'd become uninsured could be higher or lower, she said.
Sometimes, patients only learn they lost coverage when they need health care, said Susan Martin, director of case management at the Medical Center of Aurora. Going to a hospital is stressful under any circumstances, and needing to regain coverage just adds to that, she said.
"They're here in a medical crisis, and we're asking, 'Do you have your last three months of bank statements?' " so they can try to sign the patient up for Medicaid again, she said.
Since 2023, the percentage of emergency room visits involving uninsured patients has gone up, said Julie Lonborg, senior vice president of communications and media relations at the Colorado Hospital Association.
For years, the system tried to get people covered and into a regular source of primary care so they wouldn't use the emergency room unnecessarily, but it appears that progress may be reversing, she said.
Federal law requires hospitals to treat people without insurance in an emergency. The same protection doesn't apply for medical problems that aren't life-threatening, but some hospitals will go ahead and provide care, knowing they can get paid retroactively for services provided between when a person applied for Medicaid and when they got approval.
But rehabilitation centers typically demand either insurance coverage or upfront payment, so people who can't immediately go home from the hospital don't have any good options if their coverage lapsed, Martin said. Patients also can find themselves on the hook for any medications or equipment they need when they go home, such as oxygen tanks, she said.
One recent patient at the Medical Center of Aurora, an unemployed man in his 40s, didn't know his coverage had lapsed until he couldn't afford to fill his prescription for blood thinners, Martin said. He had a stroke, and the hospital couldn't find a rehabilitation center willing to take him until he had coverage, she said.
"He was in the hospital for an additional two weeks" waiting on Medicaid coverage, she said.
Marivel Klueckman, the department's eligibility division director, said they are trying to make the process easier by reducing the paperwork and increasing the share of people whose coverage renews automatically. They're also working with hospitals to make sure they quickly get paid when they sign up someone who appears to be eligible for Medicaid, and to provide people more information about where their applications stand, like pizza delivery companies do, she said.
"You know when the order is received, when it's in the oven and when it's ready," she said. "It should be the same with (Medicaid) renewals."
Other planned changes include setting up a system to track when letters to Medicaid members come back as undelivered, so they don't keep sending them to the wrong place, and making the language clearer in the department's messages, Bimestefer said.
Dr. Laura Luzietti, who works at Every Child Pediatrics, told lawmakers at a meeting earlier this summer that about 11% of the practice's visits are with uninsured children, up from about 8% before the unwinding. Every Child has four safety net clinics in the Denver area and eight school health centers in Aurora, Fort Collins and southwest Colorado. But that figure doesn't reflect families that are skipping care after finding out they lost their coverage, or are forgoing services the practice doesn't offer, such as X-rays, she said.
Generally, Medicaid presents a trade-off: Its reimbursements are lower than commercial insurance, but it offers stability and is easier to deal with, Luzietti said. It no longer has those advantages because making sure patients stayed covered is just as difficult as working with commercial insurers, she said.
"Preventive care in kids, especially young kids, can't wait for three months" while their parents try to regain coverage, she said.
Providers staffed up to care for the increased number of people with Medicaid coverage during the public health emergency, and the contraction has been painful for many of them, Bimestefer told lawmakers at the early summer meeting. During the public health emergency, about 4.6% of Coloradans didn't have insurance, and rebounding to the pre-pandemic level of 6.5% will feel like a massive increase in uninsured patients, she said.
Even if people do find other coverage, they have to get used to out-of-pocket costs, such as copays and deductibles, that generally come with commercial insurance, Bimestefer said. If a patient can't afford their deductible and doesn't pay, that still leaves the provider in the lurch at a time when they're already losing federal pandemic recovery funds, she said.
"To the providers, it feels like no insurance," she said.
Colorado and some individual cities raised their minimum wages, which may push some households above the income cut-off, Bimestefer said. A person working a full-time minimum-wage job for 50 weeks of the year in Colorado would earn just under $29,000, which is more than $8,000 too much to qualify for Medicaid as a one-person household.
Bethany Pray, chief legal and policy officer at Colorado Center on Law and Policy, said that doesn't explain the drop in Medicaid rolls, and states' success in keeping residents covered doesn't correlate with their minimum wages. Colorado's electronic management system has had problems for 20 years, forcing human staff to process more applications and increasing the odds of errors, she said.
"Our inefficiency drives up costs year after year," she said. "We really don't want to be where we were before the pandemic."
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