Jul 5, 2024

Bethany Pray serves as CCLP's Chief Legal and Policy Officer. Her areas of expertise include regulatory analysis and advocacy for Medicaid and commercial coverage, access to behavioral health benefits, Medicaid eligibility and much more.Staff page ›

Recent articles

CCLP’s 2024 legislative wrap-up, part 2

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs. Part 2/2.

CCLP’s 2024 legislative wrap-up, part 1

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs.

CCLP testifies in support of Clean Slate updates

Bethany Pray, CCLP’s Chief Legal and Policy Officer, provided testimony in support of House Bill 24-1133, Criminal Record Sealing & Expungement Changes. CCLP is in support of HB24-1133, as it is one of our priority bills.

Facing the facts: Advocates present to the JBC on glitch-plagued PHE Unwind

On June 20 the Colorado Health Policy Coalition (CHPC) brought a panel of speakers to the Joint Budget Committee (JBC) to discuss the Public Health Emergency (PHE) Unwind. The PHE Unwind is the process all states have gone through to re-examine eligibility of all Medicaid enrollees. Aiming to underscore the urgency of the situation, CCLP’s Bethany Pray and other coalition members testified on the numerous challenges for Colorado residents, the providers who rely on Medicaid reimbursement to provide care, and the counties who process eligibility.

Colorado has nearly[i] made it through the process of re-examining eligibility for the almost 1.8 million Coloradans who were enrolled in Medicaid during the COVID-19 PHE. Health First Colorado, our Medicaid program, was a lifeline for over 30 percent of Colorado residents, helping Colorado weather COVID-19 and connecting people to low- or no-cost behavioral health care, vaccinations, primary care, medications, and more.

The PHE Unwind has been painful, marked by processing backlogs, inaccurate notices, unprecedentedly high rates of denials, and soaring application rates. Those application rates were largely driven by people who were dropped from coverage despite still meeting program requirements, who were then forced to scramble to regain coverage. While Colorado’s Medicaid coverage policies are more generous than those of many states, endemic operational problems and inefficiencies have prevented those policies from having the intended impact. As of May 2024, Colorado was second in the nation in the percentage of enrollees terminated from coverage.

The PHE Unwind portion of the JBC meeting opened with a presentation by Kim Bimestefer, the Executive Director of the Department of Health Care Policy and Financing (HCPF). HCPF is the state agency responsible for administering Medicaid. Following questions by members of the JBC, CCLP’s Bethany Pray presented on the data around the PHE Unwind and the state’s inefficient processes. She was followed by Megan Bowser, a parent of a child with disabilities and the incoming Executive Director of Family Voices Colorado, explaining the enrollee perspective; Laura Luzietti, a pediatrician and Executive Director of Every Child Pediatrics on the impact on providers; and Jamie Ulrich, Human Services Director of Weld County, bringing county insights.

Ms. Pray’s testimony affirmed that all stakeholder groups, including residents, providers, and county employees, are hampered by old technology and overly complex processes. She urged policy makers –- the legislature and administration – to take a clear-eyed look at the dysfunction of our Medicaid eligibility system.

CCLP believes it is imperative that the state of Colorado find a path to a more efficient Medicaid system that can keep eligible people enrolled, support a robust provider network, and allow counties to function smoothly. What we don’t need is a positive spin on the situation, which merely obscures the truth.

More detail on CCLP’s presentation and the sources behind it can be found in this outline of CCLP talking points. Because time was short — with just 30 minutes available for the entire CHPC panel — there was little chance to debunk misleading information offered by the Department. We offer more detail on those points in the Fact Check! below. And for a deeper analysis of data regarding the minimum wage and Medicaid eligibility, be sure to check out CCLP’s new Issue Brief: Medicaid Eligibility and Wages.

Fact Check!

#1: There is no basis to believe that a large number of people have lost coverage because they transitioned to employer-based coverage.

#2: There is no basis for the claim that unemployment rates account for the differential between state disenrollment rates or that Colorado’s employment rate “has been stronger throughout the … PHE Unwind.”

  • In fact, Colorado’s unemployment rate rose slowly but steadily through the PHE Unwind, from 3.1% in May 2023 to 3.8% in May 2024.
  • Colorado currently ranks 38th for its unemployment rate. Unemployment is higher in Colorado than in most other states.
  • HCPF cites outdated February 2020 information when talking about unemployment.
  • In CCLP’s analysis, unemployment rates do not correlate with Medicaid enrollment, though that might seem logical. In fact, we see evidence that increasing unemployment rates are correlated with declining Medicaid enrollment across the country since the start of the PHE. While this may seem counterintuitive, the implications is that other factors are behind the declines in Medicaid enrollment we’ve seen in states across the country.

#3: There is no basis for the claim that Colorado’s higher minimum wage is the cause of Colorado’s high termination rate.

  • In CCLP’s analysis, increases in Colorado’s minimum wage since 2019 have had minimal impact on the size of the Medicaid-eligible population.
  • In many cases, single-adult and two-adult households working 35 hours at the minimum wage were not eligible for Medicaid in 2019. If the minimum wage had any effects on disenrollment from higher wages, that impact would have occurred well before the start of the PHE.
  • In CCLP’s analysis, there was no clear correlation between the minimum wage level of a state and Medicaid rolls, though that might seem logical. (See CCLP’s Issue Brief: Medicaid Eligibility and Wages for more.)
  • According to KFF, states that have seen some of the highest rates of Medicaid disenrollment since the start of the PHE have minimum wages of $7.25/hour, the federal minimum — if Colorado’s higher minimum wage is driving our high disenrollment rates, why do we see similarly high rates in states with lower minimum wages?

#4: Comparisons between denial rates in May 2024 and rates during the PHE Unwind are misleading.

  • Denial rates in May 2024 can’t be compared with earlier months because they reflect only terminations for the income-based population. In April 2024, HCPF instituted a policy that kept Coloradans with disabilities (a large group of at least 80,000 people) automatically maintained in Medicaid. (This is because case management system changes during the PHE Unwind resulted in a flood of problems for people with disabilities.)  The result is that May 2024 denial rates are not comparable to other months.
  • Hundreds of thousands of people have lost coverage since May 2023. If these high rates of disenrollment were to continue, it would take less than a year (May 2025) for Colorado to have zero Medicaid enrollees.
  • Even so, as unemployment continued to edge up, over 12,000 people lost coverage in May 2024 for reasons other than voluntary withdrawal.

#5: It is false that our current enrollment is higher than it was pre-pandemic.

#6: It is not simply “good news” that people who are eligible but lose Medicaid often return to coverage.

  • Such a statement would be equivalent to a statement that moving on and off Medicaid, a concept known as “churn,” is good — though it is expensive for counties and damaging to the health of Coloradans.
  • HCPF reports that a third of those who lost coverage returned to Medicaid. This suggests that at least a third of the people that are being disenrolled have demonstrated that they should never have been disenrolled in the first place — a clear signal of an ineffective eligibility process, not a sign of good news.
  • Our analysis of changes to Medicaid enrollment in states across the country indicates that states who managed to maintain a smaller share of beneficiaries whose coverage was terminated for a procedural or administrative reason also saw a smaller decrease in their Medicaid enrollments.

#7: Returning to the pre-pandemic status quo would not be a positive state of affairs.

  • There was a steady loss in Medicaid coverage before the pandemic. Despite the lack of supporting evidence, HCPF attributes that to a strong Colorado economy between 2016 and 2019.
  • CCLP’s analysis in 2019 attributed some of those losses to administrative burdens, including defective Medicaid communications and the state’s returned mail policy.
  • The rate of churn in Colorado — eligible people being terminated and having to come back on — was substantial before the unwind.

#8: State policy expansions should have yielded higher enrollment in 2024 than in 2020.

  • Since February 2020, more people became eligible for Medicaid because certain policy changes have yielded higher enrollment, including the following:
  • Meanwhile, enrollment for income-eligible children has dipped by more than 40,000 individuals. Enrollment for very low-income parents — those up to just 68% of the federal poverty level — has dropped by almost 20,000 people.
  • Economic mobility is not a likely cause: It is more common in the US, especially for Black and Latinx residents, to move down the economic ladder than it is to move up from lower income tiers.

#9: State policies, procedures, and administrative factors appear to have had a stronger impact than economic factors on Medicaid enrollment.

  • CCLP’s analysis of changes in states’ Medicaid enrollment suggests there is a correlation between states who took advantage of more flexibilities offered by CMS, the federal agency (in the form of waivers), and lower disenrollment rates.
  • CCLP found that states with fewer terminations due to procedural or administrative reasons have higher Medicaid enrollment have seen overall less loss of coverage since the start of the PHE.
  • These variables had much stronger statistical significance than economic factors we looked at, including unemployment rates and minimum wages.
  • Unemployment has been rising in most states, while Medicaid enrollment has been dropping as states unwind. As a result, unemployment is not a useful indicator of expected enrollment—contrary to what HCPF has been suggesting.

**********

[i] The Unwind is not technically complete because of an April 2024 pause on terminations for people with disabilities.

Recent articles

CCLP’s 2024 legislative wrap-up, part 2

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs. Part 2/2.

CCLP’s 2024 legislative wrap-up, part 1

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs.

CCLP testifies in support of Clean Slate updates

Bethany Pray, CCLP’s Chief Legal and Policy Officer, provided testimony in support of House Bill 24-1133, Criminal Record Sealing & Expungement Changes. CCLP is in support of HB24-1133, as it is one of our priority bills.

HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

To maintain health and well-being, people of all ages need access to quality health care that improves outcomes and reduces costs for the community. Health First Colorado, the state's Medicaid program, is public health insurance for low-income Coloradans who qualify. The program is funded jointly by a federal-state partnership and is administered by the Colorado Department of Health Care Policy & Financing.

Benefits of the program include behavioral health, dental services, emergency care, family planning services, hospitalization, laboratory services, maternity care, newborn care, outpatient care, prescription drugs, preventive and wellness services, primary care and rehabilitative services.

In tandem with the Affordable Care Act, Colorado expanded Medicaid eligibility in 2013 - providing hundreds of thousands of adults with incomes less than 133% FPL with health insurance for the first time increasing the health and economic well-being of these Coloradans. Most of the money for newly eligible Medicaid clients has been covered by the federal government, which will gradually decrease its contribution to 90% by 2020.

Other populations eligible for Medicaid include children, who qualify with income up to 142% FPL, pregnant women with household income under 195% FPL, and adults with dependent children with household income under 68% FPL.

Some analyses indicate that Colorado's investment in Medicaid will pay off in the long run by reducing spending on programs for the uninsured.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

Hunger, though often invisible, affects everyone. It impacts people's physical, mental and emotional health and can be a culprit of obesity, depression, acute and chronic illnesses and other preventable medical conditions. Hunger also hinders education and productivity, not only stunting a child's overall well-being and academic achievement, but consuming an adult's ability to be a focused, industrious member of society. Even those who have never worried about having enough food experience the ripple effects of hunger, which seeps into our communities and erodes our state's economy.

Community resources like the Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, exist to ensure that families and individuals can purchase groceries, with the average benefit being about $1.40 per meal, per person.

Funding for SNAP comes from the USDA, but the administrative costs are split between local, state, and federal governments. Yet, the lack of investment in a strong, effective SNAP program impedes Colorado's progress in becoming the healthiest state in the nation and providing a better, brighter future for all. Indeed, Colorado ranks 44th in the nation for access to SNAP and lost out on more than $261 million in grocery sales due to a large access gap in SNAP enrollment.

See the Food Assistance (SNAP) Benefit Calculator to get an estimate of your eligibility for food benefits.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

Every child deserves the nutritional resources needed to get a healthy start on life both inside and outside the mother's womb. In particular, good nutrition and health care is critical for establishing a strong foundation that could affect a child's future physical and mental health, academic achievement and economic productivity. Likewise, the inability to access good nutrition and health care endangers the very integrity of that foundation.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides federal grants to states for supplemental foods, health care referrals, and nutrition information for low-income pregnant, breastfeeding and non-breastfeeding postpartum women and to infants and children up to age five who are found to be at nutritional risk.

Research has shown that WIC has played an important role in improving birth outcomes and containing health care costs, resulting in longer pregnancies, fewer infant deaths, a greater likelihood of receiving prenatal care, improved infant-feeding practices, and immunization rates

Financial Security:
Colorado Works

In building a foundation for self-sufficiency, some Colorado families need some extra tools to ensure they can weather challenging financial circumstances and obtain basic resources to help them and their communities reach their potential.

Colorado Works is Colorado's Temporary Assistance for Needy Families (TANF) program and provides public assistance to families in need. The Colorado Works program is designed to assist participants in becoming self-sufficient by strengthening the economic and social stability of families. The program provides monthly cash assistance and support services to eligible Colorado families.

The program is primarily funded by a federal block grant to the state. Counties also contribute about 20% of the cost.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

Child care is a must for working families. Along with ensuring that parents can work or obtain job skills training to improve their families' economic security, studies show that quality child care improves children's academic performance, career development and health outcomes.

Yet despite these proven benefits, low-income families often struggle with the cost of child care. Colorado ranks among the top 10 most expensive states in the country for center-based child care. For families with an infant, full-time enrollment at a child care center cost an average of $15,140 a year-or about three-quarters of the total income of a family of three living at the Federal Poverty Level (FPL).

The Colorado Child Care Assistance Program (CCCAP) provides child care assistance to parents who are working, searching for employment or participating in training, and parents who are enrolled in the Colorado Works Program and need child care services to support their efforts toward self-sufficiency. Most of the money for CCCAP comes from the federal Child Care and Development Fund. Each county can set their own income eligibility limit as long as it is at or above 165% of the federal poverty level and does not exceed 85% of area median income.

Unfortunately, while the need is growing, only an estimated one-quarter of all eligible children in the state are served by CCCAP. Low reimbursement rates have also resulted in fewer providers willing to accept CCCAP subsidies.