Corey Dion Lewis (00:03.054)
Hello everybody. Thank you for listening to the Healthy Project podcast. I'm your host, Corey Dion Lewis. I have a great guest with me today. I have Catherine Hempstead, senior advisor for the Robert Wood Johnson Foundation, policy advisor. Catherine, thank you so much for being here. I really appreciate it.

Katherine Hempstead (00:21.996)
Oh, sure, it's a pleasure. Nice to be here.

Corey Dion Lewis (00:26.346)
Yes. So, you know, before we get into the conversation, can you tell the people a little bit more about yourself and what gets you up in the morning?

Katherine Hempstead (00:33.598)
Well, I work on a lot of health and healthcare issues at the Foundation. I've been there about almost 12 years. Before that, I was in state government in my home state of New Jersey in the department of health and senior services at the center for health statistics. So I've always loved to work with data and love to think about how we bring data to make people's health better. And I guess at the foundation, I would say the thing that's been getting me up in the morning.

for the past 12 years at least has been coverage and doing whatever we can do to make sure everybody has access to affordable healthcare, which means working with a system that's deeply flawed, but trying to make that system as good as it can be in the face of lots of times disagreement and discord about whether or not we should even do that.

Corey Dion Lewis (01:28.458)
Right, I'm sure that every day is maybe a little bit different. There's a lot, like you said, a lot of challenges within our system, which kind of leads into our conversation today and something that people know, but I don't think people know the severity of what's going on with the, what did I read? The great unwinding, or people have been calling it with this Medicaid redetermination. For those who aren't aware,

Katherine Hempstead (01:51.99)
Mm-hmm.

Corey Dion Lewis (01:58.502)
Can you talk a little bit about what is the Medicaid redetermination? What does that mean?

Katherine Hempstead (02:01.154)
Yeah, sure. It's a great story on so many levels because I think there are a lot of important details in the here and now for people. And then I think it's also a way to just kind of take a look at our system and think about some of the things that are just not that helpful about it. But to give you the short version, during the pandemic, the federal government decided that it would be really good to try to keep as many people

covered as possible. So they put in, you know, what you could think of as kind of a continuous coverage requirement, and they asked states not to disenroll anybody from Medicaid, you know, normally states go through a procedure every year to see whether or not people are still eligible for Medicaid and people, you know, people lose eligibility for changes in income and other kinds of reasons. So you know, Medicaid is kind of a front door and a back door. And some people go in, some people go out, and there's just a annual process of redetermining eligibility. But during the pandemic,

Corey Dion Lewis (02:49.463)
Right.

Katherine Hempstead (02:56.842)
we put a halt to that. So you can think about it as sort of, there's a front door, no back door. And people came into Medicaid for the normal eligibility reasons, but nobody was getting redetermined out or being found to be ineligible. So as a result, you can imagine the population of people enrolled in Medicaid expanded a lot. It increased from roughly 70 million to now almost 95 million. So it's a huge program. Yeah.

Corey Dion Lewis (03:24.479)
Mmm, whoa.

Katherine Hempstead (03:24.814)
it's a huge program got huger. Of course it's really 50 different programs because there's a different Medicaid program in every state. And finally, at around the time that the public health emergency ended, it was time to stop that practice. So now all of the states on somewhat similar, but they have some choice over the timetable, are going through the process of redetermining their caseloads for eligibility. And so it's a...

It's a seismic coverage event because, you know, many people are estimating. We can get into some of the specifics in a minute, but many, you know, the big picture is a lot of people are expected to lose their eligibility for Medicaid. Some of those people will become uninsured. Many of them won't, but that's, you know, that's a big issue. And then there's also kind of a related issue of making sure that people don't...

Corey Dion Lewis (04:11.249)
Mm-hmm.

Katherine Hempstead (04:22.962)
inadvertently lose their eligibility for Medicaid because they have, you know, the communications breakdown around telling people what they need to do and making sure people are responding to requests for information. So there's, that's a big sort of subplot of this that's actually, you know, I think becoming more and more important. So there's a lot of, a lot of dimensions to this, but obviously it's a whole, whole lot of people changing their coverage status.

Corey Dion Lewis (04:52.11)
Right. Oh, so what are some of the challenges that these states will face as they restart eligibility reviews, like you said, for the first time since 2020?

Katherine Hempstead (05:02.498)
There are so many. I mean, it's a huge logistical issue. For one thing, a lot of people that are enrolled in the Medicaid program since, you know, relatively recent tenure in the Medicaid program have no familiarity with the concept of doing an eligibility redetermination. So they're not expecting it. They're not looking for it in the mail. They don't know anything about it. So it's very hard to get people to be aware of something, you know, that's coming that they need to respond to.

It's a little bit similar for staff. There's a lot of staff that have never been through the process before. They haven't been at the agency that long, so it's new for them. There's a huge staff shortage in a lot of the agencies. So there's like a real logistical challenge. And states have tried through many, many different channels to tell people, this is coming, here's what you do, look for this, wait for this. Every state's doing it a little bit differently. But when you think about it from sort of a...

Corey Dion Lewis (05:34.231)
Right.

Katherine Hempstead (05:59.17)
communication standpoint, it's inherently very challenging. And I think one thing that's true is that people don't like to think about insurance. They want to have it, but once they have it, they don't want to think about it. They're out there living their lives. They don't want to think about their insurance. We've found that people don't shop around for plans when they could to save money. People don't want to change auto insurance when they could save money. People do not want to think about insurance.

Corey Dion Lewis (06:11.914)
Right.

Katherine Hempstead (06:28.114)
So it's natural. And I think, you know, there've been a few surveys that have shown this, that many, many people are totally unaware that this is happening. So it's a real hurdle to overcome logistically. And then there's some politics, you know, there's some states that I think have, you know, you can think about making two kinds of mistakes, right? You can make a mistake of kicking someone off a program who really is eligible. And then you can, you know, make,

make the other kind of mistake, maybe keeping someone on a program who's no longer eligible. And some states are more worried about one kind of mistake than another. So there's a class of, you know, a small group of states that have made a big point about not wanting to have anyone on the rolls that's no longer eligible. And so they are trying to do this process as quickly as possible. And they've sort of made that their calling card, you know, that they...

they want to get through this in six months, even though they could have longer and they're going to do it super fast. And I think that, you know, the faster that you try to do this, the easier it is for there to be mistakes and for people to not get the message. So, that's a little bit of a political dimension that we're seeing in some places. But I think for every single state in the country, you know, it's hard. It's really, really hard logistical work.

Corey Dion Lewis (07:47.562)
Right. So when you say like the, like some of those mistakes, is it one of those things where a state can be like, Hey, we, we put out the information is not our fault that they didn't see it or are maybe like one of those things where they're like, Hey, if you don't, if you don't get it, you don't get it kind of a thing.

Katherine Hempstead (08:07.214)
Well, yeah, I mean, at the end of the day, like every state has, you know, some people they can renew automatically by looking at their tax return or their SNAP eligibility. And that's super, but most states can't do that. No state can do it for everybody. And a lot of states can only do it for some people. So for many states, they need to mail someone something and they need information back, or they're sending people text messages, or they're telling people to go to a website and they need people to send information back. And if they don't send information back.

Corey Dion Lewis (08:16.795)
Mm-hmm.

Corey Dion Lewis (08:31.48)
Right.

Katherine Hempstead (08:36.722)
after a certain point, they're terminated. And that's what people, I don't know if you've been following stories about this, but if you hear people talk about procedural terminations, that means that people are being terminated, not because they were found to be ineligible, but because they didn't supply the requested information. Now that's not necessarily bad. It could be the case, for example, that someone enrolled in Medicaid during the pandemic, now they work somewhere, they have employer covered insurance, they're...

Corey Dion Lewis (08:55.386)
Hmm.

Katherine Hempstead (09:05.954)
they're insured elsewhere. They've never been redetermined off because that process wasn't happening. So they get this packet in the mail and they throw it in the trash because they say, I'm not eligible for that program. I've moved on, I'm doing something else. So part of it is that, but the other part is the person who gets it and says, I don't know what this is. I don't live in this address anymore. I don't read this language. I don't understand this. And they don't respond either, but those people may be.

really are still eligible for the Medicaid program and are then losing their coverage because of the kind of bureaucracy, the process. So it's all sort of mixed up, but what's making people feel very concerned is right now the early data that's coming in, we're hearing that roughly 75% on average of all the disenrollments are what people call these procedural disenrollments, which has a lot of people concerned and a lot of them are children.

that people are falling through the cracks and didn't get the message, even though I think states tried hard, but didn't get the message and weren't able to respond to this request for information and are losing their coverage.

Corey Dion Lewis (10:10.2)
Right.

Katherine Hempstead (10:19.295)
Yeah.

Corey Dion Lewis (10:19.298)
Right. Ooh. So, yeah. So, you know, what does this mean for those who have, you know, Medicaid covers right now? Like is there, is there outside of, you know, making sure they're checking their, their mail, you know, what can they do to be proactive?

Katherine Hempstead (10:33.614)
Well, this is one of the things that I think makes it a very hard story to communicate about because it's a year long process. So, and you can't do your redetermination early. Like you can only do it when it's your turn. So you can, it's hard to get people's attention for a year. So somebody might listen to a story about this, but they're not going to get their information packet for seven more months. And so they

you know, need to kind of stay on alert. So I guess, you know, listeners that might be enrolled in Medicaid and are worried about inadvertently losing their coverage, they might want to make sure they didn't already miss something. One of the first things that everyone tried to, really, really hard to do was to make sure everybody updated their contact information. So if you happen to know that you're not living at the address that the Medicaid agency thinks that you live at.

Make sure that you're findable and you're reachable. If you worry that you might have already missed it, if you think like, oh you know there was something that came six weeks ago and I didn't pay any attention to it, maybe that was it. Check with your state Medicaid agency, you could also check with your managed care company or even a provider that you use a lot to maybe make sure that you didn't miss it. Some states are allowing people to figure out when it's going to be their turn because most states are going about it

based on the month in which you enrolled. So if you happen to have enrolled in Medicaid in May of 2020, you're gonna come up in May. Very few people probably remember when they enrolled in Medicaid. But that is some advice for people. And if people do lose their eligibility because they don't return information, but they really are still eligible, they can get back.

enrolled in the program. I mean, but there's a gap. You know, they might go to the drug store to pick up medicine they really need and find out they can't get it or other things can happen and they're going to have to, you know, call the agency and get back on. So it's, you know, it's some and, you know, inevitably some people won't get back on. So I think that when we, when we look at this issue, there's the real coverage loss of people that will

Corey Dion Lewis (12:23.854)
All right.

Katherine Hempstead (12:41.158)
will truly lose their eligibility for Medicaid. And we can talk about those people in a minute and some of those people will end up uninsured. And then you might think of this other stuff as kind of noise, like these are people, they accidentally fall off, they can get back on. The dust will all settle, it's not that big a deal. But the truth is some of those people won't get back on, because they just won't. They won't really understand why they lost their coverage and they won't get back on. So it's more than just noise, especially if it becomes

much larger than people anticipated.

Corey Dion Lewis (13:16.382)
Right, no, I understand that for sure. Can you talk about, you kind of touched on it, those people who will lose their eligibility. Can you touch on that a little bit and what that looks like?

Katherine Hempstead (13:21.55)
Sure. Yeah. So, if you think about a pie, you know, like the early estimates were that 15 million people truly would lose their eligibility for Medicaid. They truly would. It wouldn't be a mistake. They would lose their eligibility. And of that pie, the estimate is that something like

3 million of them, like 20% of them, would end up uninsured. This is an estimate from the Urban Institute, sort of based on the best information using a micro simulation model, but it's still just an estimate. And the idea is that most of the people will be able to go to one of three places. CHIP, a lot of kids will be eligible for CHIP. A lot of adults and some kids will be eligible for employer-sponsored insurance, and in fact, may already be in it.

Definitely many people have two forms of coverage and many people are probably already in employer sponsored insurance. And then about 1 million people will go to the marketplace, the ACA marketplace. So who are the people that are uninsured? Who are the 3 million people? Those are basically people who are not going to take an offer to go to employer sponsored insurance or to go to the marketplace. They're going to have the opportunity, but they're not going to do it because...

it's gonna cost them a lot of money. So, for example, if you think about a person who enrolls in Medicaid, they get married, let's say. Their spouse has a higher income than they do, so they're really no longer eligible. He's no longer, or she, no longer eligible for Medicaid once you look at their household income. The spouse has employer-sponsored coverage, but a lot of employer-sponsored coverage has, you know.

not much subsidy for the spouse. So all of a sudden they're looking at, wow, $550 a month for me to join this plan. That's a lot. And if they happened to be able to go into the marketplace, they still wouldn't qualify for a huge subsidy because they have to use their household income. So it would be to many people a big price swing in what they're paying for their health insurance. And even though the government theoretically says this is affordable for you, it's

Katherine Hempstead (15:36.462)
close to the edge for them. And some people are gonna say, I have a car payment, I have student loans, I'm not doing that. So there's gonna be some people that are gonna not take offers that they have, probably because they're not gonna get a very good subsidy and they're gonna have to spend a lot of money and it seems like too much and they will become uninsured, which is unfortunate, really unfortunate.

Corey Dion Lewis (15:39.787)
Yeah.

Corey Dion Lewis (16:03.37)
Right, so you're not eligible for Medicaid because you make too much, but you don't make enough to afford health insurance. And people are gonna choose, you go into survival mode, right? You're gonna choose what you need.

Katherine Hempstead (16:12.03)
Yeah, yeah. Some people are going to be eligible for a highly subsidized plan in the marketplace if their income is low, but there are other people that, you know, their income maybe isn't as low, but for them it's a lot, you know, and it's a big change from zero to, you know, multiple hundreds a month. A lot of people don't have that and they're going to choose not to do it, you know, and it will also depend a little bit, of course, on how much they need.

Corey Dion Lewis (16:34.734)
Yeah.

Katherine Hempstead (16:41.834)
you know, to use the healthcare system. If you're, you know, in treatment for something and you're getting, you know, medications that you need, you're gonna be more likely to stay on. But certainly that's where we see the loss and coverage is gonna come from.

Corey Dion Lewis (17:00.866)
Right. So as I was doing some research and trying to learn more about this before we had our conversation, I read an article talking a lot about, and you've already kind of touched on it, the communication gap. And it said something like 62% of adults with family Medicaid enrollment haven't been informed.

about upcoming eligibility redetermination. Can you shed a little bit more light on that communication gap or is there a communication gap there?

Katherine Hempstead (17:34.198)
Well, I mean, if you, yes, and I think it goes back to the fact that people are living their lives. They're not thinking about, you know, where they get their coverage or what might happen to it. Most of them haven't had to think about it in years because they've not done any kind of redetermination thing. A lot of people don't even know that the program they're in is Medicaid because it has a different name. Every state calls their program something different. They

Corey Dion Lewis (17:50.094)
Mm-hmm.

Katherine Hempstead (18:02.262)
Don't connect that story to them. I mean, if you look at what states have done, it's impressive. I mean, you say, wow, you've got this in 20 languages, you're using social media, you're using this, you're using that. I've seen some ads about it in New Jersey. They're doing a lot. I mean, some states are doing more than others, but I still think no matter what you do, it's a hard message to get across. Another important part of the communication story is the, are the managed care organizations, because they're...

motivated very much from a business perspective to not lose their members, especially if they don't need to lose their members. So they have been really, you know, getting on their members to update their contact information and, you know, trying to spread the word to people. So I think if you look at the efforts, they seem pretty impressive, but at the same time, you can imagine it's a huge...

bridge to get to people about this. And so, you know, I'm not at all surprised to hear that a lot of people don't know. And it's also, like I said, it's like a drumbeat that has to go for a year. You know, it's really hard to say, keep paying attention to this for a year. And someday you're going to get something in the mail and then you have to do something, you know. People might have updated their contact information and then they're going to move again. You know, so it's a, it's a, you know, and I think from a 30,000 foot.

Corey Dion Lewis (19:09.175)
Yeah.

Katherine Hempstead (19:24.966)
look, you say like, this is a crazy system. You know, it's so easy to lose your coverage, you know, and look at all the money we spend on eligibility and redetermination and all this stuff that we're doing. And it's, you know, it's the system that we have, so people should pay attention and not lose their Medicaid, but it's a very inefficient system where people's, you know, relationship with coverage can be very precarious until they finally get into Medicare.

Corey Dion Lewis (19:54.186)
Right. You know, that's a lot. And it's, you know, with what you do, you know, at the Robert Wood Johnson Foundation, and really being, I'm sure this is your day to day. This is your, no, you're okay. This is what you do every day and trying to figure out the best way to communicate this stuff. You know, what?

you know, what kind of things, you know, where's the light at the end of the tunnel with, do you feel like there can be a positive outcome from, again, it's a year and a lot could happen, but with what you guys are doing over there, you know, do you feel like there's some positive things that can come from this?

Katherine Hempstead (20:42.254)
Well, I mean, I think many people are reflecting, like big picture, small picture, okay? Small picture, I think, this problem that's coming up right now is an extreme version of something that happens all the time. Because if you know anything about Medicaid, you've heard people talk about churn, which is people, you know, just not during the pandemic, just normal life, missing that redetermination thing, falling off Medicaid, even though they're eligible, then.

coming back on, maybe having missed some important appointments or missed vaccinations, whatever, coming back on, turning off again. And people use that word turn, just people come on and off either because of missing the re-determination stuff or their income just bopping like up and down. You're eligible, you're not eligible, you're eligible, you're not eligible. So I think that a silver lining, okay, might be that we've learned a lot about things to do to minimize that.

Corey Dion Lewis (21:32.043)
Right.

Katherine Hempstead (21:41.814)
you know, a lot of things are going wrong right now. I sort of feel like once we get back to business as usual, everybody's gonna be better at this. And the plans, you know, for the plans, it's, you know, a lot of times what's good for business isn't good for people, you know, but this is one time that their interests align with sort of the, you know, the enrollees interests and staying covered, keeping people covered. So I feel like the plans and the state agencies are,

learning new, more efficient ways to work, that maybe once we get past this, we'll see less churn. That would be a great silver lining. We solved a lot of problems. And sometimes during wars and other bad catastrophes, you'll learn new ways to do things that then you keep doing them. I think on the other hand, you say, whoa, what a stupid system. This is crazy. We ought to have a more continuous coverage kind of all the time, or we should have universal.

Corey Dion Lewis (22:21.24)
Right.

Katherine Hempstead (22:39.726)
coverage for everyone that's maybe kind of basic, but low cost. So people are always eligible for basic coverage because think about how much we spend as a society doing eligibility redetermination. So I think that there are some incremental silver lining things that you can see, but then I think you can look at it, big picture and say, wow, like nobody would have ever designed this system. It's really crazy.

Corey Dion Lewis (22:59.476)
Mm.

Corey Dion Lewis (23:07.642)
Right. No, I understand that. It kind of, you know, it sounds like COVID and that whole thing shine the light on where there can be some adjustments, possibly if we all work together. And so some good and bad, you know, there's some good and bad in everything.

Katherine Hempstead (23:25.946)
Well, yeah, I mean, and I think COVID made us say, wow, it really matters if people don't have access to healthcare, that's actually a big problem when there's an infectious disease that's killing everybody. So let's do some things that would make it easy for people to stay covered. And so we did a bunch of things, including this. And, you know, is it not important anymore for people to stay covered? Of course it is, you know, but we sort of have to go back to our status quo system, but that's a system that leaves a lot of people

Corey Dion Lewis (23:34.225)
Yeah.

Corey Dion Lewis (23:50.479)
Yeah.

Katherine Hempstead (23:54.986)
in the lurch and there's definitely gonna be, you know, some people that are gonna get, lose their eligibility for Medicaid and see what their other options are and say, no thanks. You know, I can't pay $550 a month for coverage or whatever. So, you know, they're gonna be on your short again with all the downsides for them and for society that come with this. So I think there's some, you know, big picture and small picture lessons that come out of this for sure.

Corey Dion Lewis (24:26.406)
Awesome. Well, we'll leave it with that. Catherine, again, thank you so much for being here. For those that are listening, that want to connect with you, or if there's any resources that you may have, where can they reach out to you?

Katherine Hempstead (24:38.102)
Well, I can be found at KHempstead, rwjf.org. Also, I'm still on Twitter or X or whatever it's called, KHemp64, at KHemp64. I'm on LinkedIn. I did join Thread, but I haven't figured out what to do there yet. So I just go on, let's go on and look around. And I do have some good data sources like...

Corey Dion Lewis (24:48.498)
Yeah.

Corey Dion Lewis (24:58.062)
Yeah, I don't think anybody has.

Katherine Hempstead (25:03.778)
Kaiser Family Foundation tracks a lot of stuff at the state level, and there's also a great state tracker from Georgetown, so I'll send those links over to you to put on the website in case people wanna see what's going on in their state.

Corey Dion Lewis (25:19.322)
Awesome. Well, again, thank you so much for being on the podcast and everybody. Thank you for listening. I'll holler at you next time.

Katherine Hempstead (25:25.058)
Thanks.