With the ending of the COVID-19 public health emergency and passage of the Consolidated Appropriations Act of 2023, provisions implemented in 2020 during the height of COVID-19 to keep eight to 24 million Americans continuously enrolled in Medicaid came to an end.  With additional federal financial support, Medicaid by 2022 covered more than 85 million Americans. But with the emergency now official ended and states needing to re-determine the eligibility of millions of those who became and remained enrolled during the pandemic more than 11.7 million Americans have lost this coverage including an estimated 3.5 million children.

Medicaid Unwinding to Loss of Coverage

Despite guidance from the Administration and growing recognition of its challenges, it has become clear that the so-called Medicaid unwinding process, the process of redetermining eligibility for those who remained continuously enrolled during the pandemic, has not gone smoothly. Though it may on its face seem simple, the process of informing enrollees about potential disenrollment and their need to renew coverage in fact is complex and has been implemented differently among the states.

As the unwinding proceeds, it is worth considering how Medicaid and the loss of this coverage may potentially impact public health preparedness efforts for as much as has been written about the challenges and implications of the unwinding process, these implications appear to be somewhat overlooked.

Medicaid and other health care coverage bolsters emergency preparedness

At the height of COVID-19 million Americans lost their jobs. Because roughly 49 percent of Americans obtain their own or family health coverage from their employer, with about 21 percent covered by Medicaid, 14 percent by Medicare and 6.1 percent by non-group insurance (e.g., Affordable Care Act qualified health plans) and 8.6 percent uninsured (as of 2021), this meant that millions eventually lost their employer-based health coverage as well. 

This challenge has not ended with the COVID public health emergency. Study methods can be debated but at the end of the day those with insurance coverage were in a better position to seek and obtain care than those without coverage; this disparity may have been one factor in the United States’ response to COIVD being less vibrant than public health preparedness assessments alone would have suggested. One group, for instance, estimated more than 300,000 lives might have been saved had the US health care system been differently structured to support more universal coverage. Residents of states that expanded Medicaid were less likely to engage in practices that may have increased their COVID risk (such as excessive drinking and smoking) and had a source from which to seek care. 

Medicaid as Infrastructure

Both during pandemics and under more normal circumstances, having Medicaid coverage can help decrease morbidity and mortality across a wide range of conditions. Medicaid also beyond individual benefits has benefits to the public health system as a whole such as enhancing the infrastructure needed to share data, supporting certified community behavioral health clinics and federally qualified health centers, and partnerships between Medicaid and other public health programs that support health-related social needs such as food or housing. Such system and individual benefits can help bolster resilience during pandemics and other emergencies.

Medicaid coverage especially supports those most vulnerable to pandemics and other health emergencies

As COVID-19 spread throughout the nation in 2020 and 2021, it soon became apparent that some populations were more at risk than others. Persons of color. American Indians/Alaska Natives. Older adults. Persons with psychiatric conditions. Those with intellectual disabilities. Recognizing such disparities, the federal government established the COVID-19 Health Equity Task Force within the HHS Office of Minority Health. In its final recommendations and implementation plan, the Task Force recognized Medicaid’s critical role for  supported such steps as expanded eligibility, additional Medicaid funding, enhanced reimbursement for Medicaid providers and parity for behavioral health services.

In addition to COVID-19, Medicaid has supported responses to other emergencies and disasters impacting vulnerable populations such as Zika virus, the water crisis in Flint and response to Hurricane Katrina. Those with Medicaid coverage are can work with their health care providers to prepare for emergencies (such as obtaining extra prescription medications) more easily than those lacking health coverage.

Medicaid coverage supports the nation’s response to the opioid crisis

Before COVID-19, in October 2017, the Trump Administration declared a public health emergency for the opioid crisis. This initial declaration has since been renewed, most recently at the end of September 2023. Overdose deaths due to opioids, alcohol and other drugs (methamphetamines, cocaine) increased  during the pandemic, with the number of deaths exceeding 100,000 in 2022 and deaths related to alcohol misuse also exceeding 100,000 in 2021. The pandemic and other factors have increased the need for behavioral health care. 

With as many as 40 percent of Medicaid enrollees having a mental health or substance use disorder, Medicaid provides key behavioral health services that are critical to substance use disorder prevention and treatment. Though estimates vary, the cost of the opioid crisis has been calculated to exceed $1 trillion due to health care, criminal justice and other costs. Beyond the opioid crisis, Medicaid can also provide services to those impacted by other disasters and emergencies such as hurricanes, droughts, mass violence and other challenges. Medicaid can serve as a model for other programs, including in the private sector. For instance, Medicaid’s increasing efforts address health-related social needs such as food and housing can serve as a model for other public and private programs.  

Decaying Infrastructure not Limited to Trains

For years, the American Society of Civil Engineers has noted America’s decaying physical infrastructure, which we’ve seen manifested in recent incidents such as train derailments. Medicaid coverage similarly is one major pillar of our nation’s public health infrastructure. With this pillar weakened, as it is being weakened by the ongoing unwinding process, so too does individual and collective health security and preparedness further erode. 

As a nation we will be better prepared to confront current and ongoing public health challenges with millions of our fellow citizens covered by Medicaid rather than millions lacking this health coverage. We cannot pretend otherwise—and we shouldn’t.

Mitchell Berger, MPH has worked on public health and behavioral health programs at the federal and local levels including the Department of Health & Human Services. The opinions expressed are solely those of the author and should not be imputed to any public or private entities.