About 1.5 million Minnesotans with Medical Assistance or MinnesotaCare must complete re-enrollment paperwork to re-determine their Medicaid-eligibility status by May 2024. The already significant disparities with access to health insurance for communities of color make this a health equity emergency. Leigh Grauman, a licensed social worker and director of training and policy implementation at Portico Healthnet, explains the process, barriers to renewal and how people can help.
About 1.5 million Minnesotans with Medical Assistance or MinnesotaCare must complete re-enrollment paperwork to re-determine their Medicaid-eligibility status by May 2024. The already significant disparities with access to health insurance for communities of color make this a health equity emergency.
Leigh Grauman, a licensed social worker and director of training and policy implementation at Portico Healthnet, explains the process, barriers to renewal and how people can help.
Relevant links:
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Leigh Grauman
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is Off the Charts.
Steven Jackson:
Welcome back, everybody, to our show. We have today Leigh Grauman, who is a licensed social worker and director of training and policy implementation at Portico Healthnet. Welcome.
Leigh Grauman:
Thank you. Very happy to be here.
Steven Jackson:
Thank you for being here.
Kari Haley:
Yeah, thank you so much. So you're here to really kind of help talk to us about Medicaid, specifically the re-enrollment with the Reconciliation Act. Can we first start off with maybe talking about what is Medicaid? Because I feel like there's a lot of terms that are thrown out there right now, but the big term Medicaid, which is what we're talking about, what is that and who does it apply to?
Leigh Grauman:
Absolutely. So Medicaid is a public health care program for people with low income. And in Minnesota, our Medicaid program is called Medical Assistance or MA. So you might hear people referring to having MA or enrolling in Medical Assistance. What they're talking about is our programs, our state's Medicaid program.
Steven Jackson:
There was what's called a Reconciliation Act passed at the end of 2022 and it made some significant changes that affect families every day.
Leigh Grauman:
One thing I think is important to know is kind of what a renewal is or what a redetermination is because that's really what we're talking about with this change. So typically when people are enrolled in the Medicaid program, they get their health insurance through Medicaid. They're typically required to complete something called a renewal or a redetermination once a year. And essentially what that is is sending in paperwork or proofs of your income, for example, to confirm that you're still eligible for that program and that your health insurance coverage can continue.
During the COVID-19 public health emergency, those renewals were put on pause. So starting in March of 2020, there were these continuous coverage protection rules that were put in place that made it so people didn't have to complete that renewal process every year. We wanted people to be able to maintain their coverage during the height of a global pandemic, be able to access the services and testing and care that they needed.
So renewals were on pause for three years. People were able to maintain their Medicaid, Medical Assistance coverage during that time, and we now have more people enrolled in the program than ever before. There's 1.5 million Minnesotans, one in four Minnesotans who have their health insurance through a public health program, so either Medicaid or our Minnesota care program.
And now that these continuous coverage rules expired, which is what you were referring to, Dr. Jackson, they expired at the end of March. Now those renewals have to start again. So that means that 1.5 million Minnesotans are going to have to take action sometime between now and May of 2024 to have their eligibility renewed, and if they don't take that action, they'll lose their coverage.
Steven Jackson:
Number one. That's a lot of people. And I'm sure with that number of people, there are some, and maybe many that aren't aware of the implications of this act. They may not even be aware that there was an act passed that's going to affect them directly. So what challenges, and some kind of go without saying, but just from your expert lens, what challenges does that pose immediately?
Leigh Grauman:
There's so much concern going into this renewal process. The most recent survey that I've seen, Kaiser Family did a survey of Medicaid enrollees and found that 65% of people enrolled in Medicaid are unaware that renewals will be resuming.
Steven Jackson:
Sixty-five percent.
Leigh Grauman:
Sixty-five percent.
Kari Haley:
That's a lot of people who answer a survey specifically, too.
Leigh Grauman:
Exactly.
Steven Jackson:
Wow.
Leigh Grauman:
So those are people who are unaware that they're going to need to take some action to maintain their coverage in the coming year. So that's a huge concern. The other thing that I think comes into play with this is we know that throughout this, they're calling it the unwinding kind of this first year of renewals, restarting again. During this unwinding period, people will lose coverage due to no longer being eligible, right?
Maybe someone first applied when they were laid off during the pandemic, they enrolled in Medical Assistance, our state's Medicaid program, but now they have a new job, they're earning more income, they're no longer eligible. Some people will lose coverage for that reason, and that's an accurate eligibility determination.
What we're really concerned about is the people who are going to lose coverage simply because of technical reasons, simply because of not completing the paperwork. We are recording this in June. I understand it's going to come out in September, but right now in June, nationwide, we know that over a million people have already lost their Medicaid coverage and 76% of them-
Steven Jackson:
Wow.
Leigh Grauman:
... 76% lost that coverage, not because of eligibility reasons, but simply because they didn't fully complete that paperwork.
Kari Haley:
Those are astounding numbers. I mean, that's kind of crazy to even wrap your head around specifically because it's all based on a paperwork or a technicality or a small piece that maybe they didn't know what they needed. So to help people through this process, what kind of things did they need for that paperwork? What information should they be looking for? What should they be gathering in order to continue or re-enroll into Medicaid?
Leigh Grauman:
Very good question. I've got a few answers for you. So the first thing I think that's so important is for us to just be raising awareness as much as we can, which is part of why I'm so grateful to be having this conversation with all of you. If we're talking about one in four Minnesotans who are going to need to take action to maintain their coverage in the year ahead, that's our friends, our colleagues, our neighbors. So talking to people is an important step.
Actions that people can take to help ensure that they're able to successfully get through that renewal process. Number one is making sure that your contact information is up to date with your county of residence. So the way that the renewal process works, it's paper-based. It's sent through the mail and it's going to be mailed to the address that is on file with your county. So if you've moved within the past three years and haven't updated that address with your county, your renewal paperwork's going to that old address, you're not going to receive it and you're at risk of losing coverage. So updating that contact information is really important. There's a website, the Department of Human Services put together a website that has the phone numbers for all of the different counties where people can call. And that's something that navigator organizations like Portico and Health Plans are helping with those address updates as well. So the contact information is step one.
I think the other thing is opening and responding to mail from the Department of Human Services. It sounds-
Kari Haley:
Nope-
Leigh Grauman:
That simple, but it can be very overwhelming for people receiving paperwork and not knowing what to open. So they're sending out the renewal notices in Minnesota with a special envelope that has a blue circle on it, and it says, "Important information open right away." If you receive that envelope, open it. It means that you have to take action to maintain your health insurance coverage.
Kari Haley:
It's not spam.
Leigh Grauman:
Exactly. Exactly.
Steven Jackson:
Yeah, please take note for those that are listening.
Leigh Grauman:
And that's another thing too, to see an example of what that looks like. The Department of Human Services has pictures of it on their website. They're really trying to get the word out, so opening and responding to that mail.
I think the other thing is connecting to navigators. So organizations like Portico, we have trained certified navigators on staff, and our whole job is helping people apply and renew their coverage. And we are based in communities. We speak multiple languages. We provide our services free of charge, so for people who need help, connecting with that help is really important. And Portico is a great organization. There's hundreds of navigators throughout the state. MNsure has an sister directory where you can look up and find a navigator in your area. You can search by language spoken. So connecting with help I think is another important piece of that puzzle.
Steven Jackson:
Yeah, those are really good actionable steps. And it makes me think about some of the inequities that are properly perpetuated by all this. And for example, if you are a person of low income and perhaps maybe you don't have internet access or maybe you don't have a TV in your home or you don't have access to this type of information, then you are probably going to lose coverage. Speak a little bit to maybe some of the inequities that we see and play a big role in some of what we're talking about.
Leigh Grauman:
Anytime that the renewal process happens, like I mentioned, there's people who lose coverage because they're no longer eligible. And there are people who lose coverage just because they're not able to complete that paperwork. Going into this huge undertaking that we're embarking on with the resumption of renewals, it's hard to predict how many people are going to lose coverage because of not completing paperwork.
But we have years and years of history and experience in this state to tell us the groups that are most likely to lose their coverage for these procedural reasons. It's people of color, it's people who speak a primary language other than English, it's people who are experiencing homelessness or move a lot. People with low income, which is the very population that the Medicaid program is designed to support-
Steven Jackson:
Exactly.
Leigh Grauman:
... it's difficult to complete the paperwork, but also just report and prove your income when you're in that situation where you maybe are working multiple jobs or your income varies.
Kari Haley:
Sure.
Leigh Grauman:
So there's all these barriers. So we know the populations that are most at risk for losing coverage. And we also know those aren't distinct populations, but there's a lot of overlap that can just make those inequities even worse.
Steven Jackson:
So are there any boots on the ground efforts, maybe from Portico or other navigators that are out there that can do something as simple as knocking on doors or holding a town hall or setting up some sort of easy access program to get the information out there? What's out there to help?
Leigh Grauman:
So as I mentioned, we've got many, many navigators all throughout the state that are doing great work to try to get the word out and connect with people and help them through this process. We have navigator organizations who are based in community are trying to meet people where they already are at, at their church, at their school, at their clinic to provide that information and then that hands-on support for people who need it. We have people doing really targeted outreach to zip codes where we know that there's a high population of people that are going to need to renew-
Steven Jackson:
That's a great idea.
Leigh Grauman:
... and need that support. So that's happening. What I think I also want to say about that is the demand is going to outweigh the capacity of our navigator organizations. We're talking about community-based organizations that were hit hard during the pandemic and we're doing the best that we can to staff up to meet this need, but there's a lot of challenges in that space as well.
Kari Haley:
Can you speak to, if you know of any, what can health care organizations do? So I'm just thinking, I work in the emergency department and when we have patients come in, we have a person who registers them and a lot of times they're able to help discuss financial pieces. Is this something that we could look at with health care organizations to also, when we have that point of contact with someone who we know is already a Medicaid patient by our records, to prompt them about re-enrollment or connect them with another group in their community?
Leigh Grauman:
Yes, absolutely. I think with all of this, it's, as I mentioned a couple of times now, a huge undertaking. It's really kind of an all hands on deck moment. So for health systems that have access to information around the type of health insurance that a person has, looking for ways to incorporate that into your interactions with patients, whatever that might be. Do you know that you're going to need to renew? Do you have a plan for that?
To take it even a step further for organizations that have access to actual renewal months, that's going to be really timely and specific information that you can share with your patients. So some people are able to look up someone's start date and might be able to estimate when they're going to need to renew their coverage. You can give specific guidance around when a person will need to take action. I think that piece is really important. I've heard people talking about connecting with patients in new ways, so text message reminders, calls out to people who are going to be due to renew. Maybe there could be messages in an electronic medical record portal, thing like that to pop up and encourage people to take those steps.
Steven Jackson:
Social media, who knows?
Leigh Grauman:
Yes, absolutely. It's going to take everything.
Steven Jackson:
I was quite surprised to hear you say that the renewals are all by paper. We just went back 30 years. And maybe you don't know the answer to this, but I'm just wondering why that hasn't been "updated." Why isn't it electronic or at least why isn't there an electronic option for 2023? Any thoughts on that? Not incriminating ones.
Leigh Grauman:
First, I just want to share your pain at the thought of these forms. And really, I mean, I'm giggling, but it's a significant barrier. We are talking about 13 pages that are being mailed out to people in English, and they need to go in and fill in the information and sign it and send it back. It's ridiculous. It's an onerous process.
I know that there were some efforts to try to stand up an online option that were not able to come together in time. But I think that one of the things that certainly we're continuing to push for at our organization that I think we need as a community to push for is changes in the administration of these programs. I mean, if we talk for a moment about, we have our MNsure online application and we have people who enroll in qualified health plans through MNsure. They tend to be people with higher income. If you are enrolled in a qualified health plan through MNsure, you can log into your online account, report changes online, see all of this information. We're able to do it for that population. Our Medicaid enrollees deserve that same type of access, and it's non-existent at this point.
Steven Jackson:
I'm so glad you said that. People just need to know that there are differences. And there are inherent differences in the system that again, perpetuate inequities and disparities, and it's almost like we're shooting ourselves on the foot by not making certain changes. I'm curious as to what is your why. I mean, obviously you're very passionate about this work, and it's definitely needed work to get the word out and to assist those that need assistance. If I can state it simply, what is your why? What makes you passionate about what you do?
Leigh Grauman:
I have been with Portico Healthnet for 15 years now, so I started back when I was fresh out of college. I worked as a community health worker. I was meeting directly with people, helping them complete these very same forms 15 years ago. We've got the same process, unfortunately. But meeting with people in the community, helping them apply and enroll in coverage and just kind of seeing that relief that can come from knowing that you have coverage that you're not going to be stuck with bills was what initially brought me to the work.
I've been there for 15 years now, and so the roles that I've held in our organization and our health care landscape in Minnesota has changed a lot over that time. But for me, it's really just been that connection to our mission, which is increasing equitable access to coverage in Minnesota for all Minnesotans. I think that work, I don't know, it's just part of my heart. I think there's a part of me that's like, I've got a little tenacity, too. I like to kind of just fight against the systems. And in this work sometimes it's as simple as just one pay stub is the thing that's keeping someone from accessing the coverage that they're eligible for. We're going to get that in and we're going to get that person coverage. So part of it is that tenacity piece, but more than anything, it's just that connection to the mission. And I'm really grateful to do this work and to get to do it alongside a really talented and passionate team.
Steven Jackson:
Yeah, that's awesome.
Kari Haley:
That is really awesome. Does your team foresee any challenges in particular with this renewal? Because it's going to be such a, I'm going to say massive dump of people honestly that are up for this re-enrollment because they have not needed to do that in the last three years. I know it's rolled out over a year, but still, a million people in our state? That's a lot of people-
Steven Jackson:
That's a lot.
Kari Haley:
... for a system that is paper-based to be approved and people to do what they need to do. What does your group foresee challenges associated with that?
Leigh Grauman:
So many challenges associated with it. So part of it is it's an unfamiliar process to people who are enrolled in the program, and we've talked about this a little bit. Just getting the word out, providing that support, having an adequate navigator workforce to provide that hands-on support for people who need it is one thing. We're also really concerned about the workforce at the county and state level, the people who need to process all of this paperwork.
Steven Jackson:
That's right. I was thinking the same thing.
Kari Haley:
That's a lot of processing,
Leigh Grauman:
Right. And so what happens if the counties are falling behind on processing? And does that mean that people could have a gap in coverage? One of the things I'll say is just this is such a unique time and the guidance from the federal level is evolving. So two months from now when this comes out, there might be different things in place. So I like to see that there's been some creativity around how can we do things a little bit differently? Can we extend deadlines, things like that. But yeah, we have a lot of concern just from a workforce alone standpoint.
I think one other thing that's important to talk about as part of this conversation, I know we're focusing on renewals, but kind of just getting back to our earlier conversation, Dr. Jackson. Is like, yes, renewals is happening and there's so much attention on this process right now, which is warranted. It's a huge undertaking. But this is happening at a time where we have already just really significant disparities in terms of access to health insurance across race and ethnicity in our state.
So during the COVID-19 public health emergency, over the past three years, Minnesota's statewide uninsured rate reached a historic low. We have 4% of Minnesotans who are uninsured. That's great. However, during that same time period, if we look at BIPOC Minnesotans, the uninsured rate actually increased from around 7% uninsured to over 10% uninsured. And that's even with all of these protections in place and not being required to complete a renewal. So we've got existing and worsening disparities in terms of access to health insurance in our state. The concern is that that's going to get even worse as we go throughout this renewal process.
Steven Jackson:
I don't know. It's a bit scary because there's no quick solution. And I mean, we need people like you and your team and other teams that have committed to, I mean, doing the hard work. I mean-
Kari Haley:
It's hard work.
Steven Jackson:
You've got a million people. I mean, that's astounding. I can't even-
Kari Haley:
Yes. You can't even really grasp that number.
Steven Jackson:
... fathom that.
Kari Haley:
You can't grasp that number, and that's people who may lose coverage to their health insurance plan, their access to health care.
Steven Jackson:
This is obviously a problem. I mean, this is a problem. It's a blaring problem. Is there any assistance from state or federal entities? Because I mean, there are a lot of, you got the Affordable Care Act. I mean, you just have a lot of things that were put forth to help as many people as possible. What are the big wigs saying about this and are they saying, "Well, let's jump in and help?" What's up with that arena?
Leigh Grauman:
Thankfully, there was legislation passed in this most recent session in Minnesota that allowed for more funding for counties and states to staff up to meet this need to get more creative around how they're reaching out to people. So the Department of Human Services is texting enrollees about Medicaid enrollments.
Steven Jackson:
There you go.
Leigh Grauman:
That's a first. That's something that's new. So that's happening. There's been some additional funding for community-based organizations, navigator organizations who are doing that work. So that's been positive to see. I think there's much more that's needed.
And the other thing that I try to keep bringing up and pushing for when having these conversations is it seems to me that our focus, especially around the funding right now, is just on this one year unwinding period. And yes, we need support and there's a lot of work that needs to be done over this next year, but the work is not going to end 12 months from now.
Steven Jackson:
Yeah, that's right.
Kari Haley:
That's right.
Steven Jackson:
These are longstanding problems and supports that are needed, and so we really need to think beyond this next year when we're thinking about solutions moving forward.
Kari Haley:
That's a lot just to sit and think about, honestly. Because I feel like as a provider, we don't necessarily think about this day to day, and it's not at the top of our radar by any means. But it's such an important thing for our patients that even in the provider world, thinking about getting the word out, not just to the people it affects, but the providers of the patients so they can talk to their patients about it or talk to their people about it. Because it's so important, so, so important. And it's really scary to think about that we don't have a specific plan. There's not one special little thing that we can do to make it all better or to make the problem suddenly become easier. It is a lot of hard work for this problem, and there's not a clear solution to it.
Steven Jackson:
How can we as health care, and maybe we've alluded to that somewhat, but as health care providers like myself, Dr. Haley. What can we do? Is there something that we can do in the doctor's office? Your doctor's office is a little bit different than mine?
Kari Haley:
It's a little louder, probably.
Steven Jackson:
A little louder, a little more emergent. But is there a message you can kind of speak to or send to health care providers across the nation in terms of what we can do in our purview to maybe contribute some way and making this less of a problem?
Leigh Grauman:
Thank you so much for that question. I think, again, it gets back to first just high level raising awareness. Do you know if you have Medicaid you're going to have to take action to maintain your coverage in the next year? And then if we can be more specific with the timing around that, people have no idea what month they're going to need to renew in general. It is tied to the time you first applied for medical assistance, which maybe was three years ago. People have no idea.
There's a website where people can go online, the DHS renew my coverage website where you can look up your renewal month. So that's a resource I want people to be aware of. But as providers, if you have access to those renewal dates or your billing departments do, sharing that with patients is huge. And I think proactive direct outreach to people that's specific to them around the time that they need to renew is going to be really essential.
Steven Jackson:
I mean, I know personally I've been educated. I've been definitely educated. I mean, I've heard about this, but I feel like, wow, now that I know more, I'm even more concerned about its impact or its potential impact. I mean, I'm going to commit to doing some digging myself. I'm curious as to how much groups like Patient Financial Services, like what role do they play in this or do they play a role in this and those kinds of things. Because I'd like to help, I mean, this is happening and we got to think about that.
Kari Haley:
Yeah, I was just trying to think, brainstorm while we were talking. What's something that I could do? And I mean, one thing really easy is probably getting that website and just putting it in my discharge paperwork for people who are discharged with Medicaid. Say, look this up and remember to re-enroll, and I can make a dot phrase out of that. That's super easy.
Steven Jackson:
That's true. That's true.
Kari Haley:
And that's something we can share for everybody, and that can be, everyone gets that piece of paper when they get discharged or their clinic summary. It's all there. You can usually put that in there.
Steven Jackson:
That's true.
Leigh Grauman:
I love that idea. There's so many resources out there. And like I mentioned, there's this DHS website. They put a lot of work into it. You can go on there, you can look up your renewal date. You can see what the envelope is going to look like. There's a video you can watch to understand how to complete the forms. They've translated the website into a number of different languages.
I question how much that website is actually getting through to the people who need it. So as much as we can be including links and things like that, I love that idea. And I think just making sure people are aware that there is free help available in the community. MNsure navigators can really help to meet this need, especially when we're thinking about this from an equity perspective. We're a crucial part of that solution. And so again, I'll just plug the assistor directory on MNsure.org. You can look up and find an assistor in your area that speaks your language and that can help walk you through this process.
Steven Jackson:
That's excellent. Thank you for saying that. And ever so often, we have episodes where I think about the title of our podcast; it's Off the Charts: Examining the Health Equity Emergency. This is a health equity emergency. Thank you for educating us and opening our eyes to an issue that we can all contribute in making better. So thank you for your expertise and your passion for this work.
Kari Haley:
Yes, thank you so much for being here and sharing all this wonderful information that we will work ourselves on continuing to inform.
Leigh Grauman:
Thank you so much for having this conversation and for the opportunity to join you. Appreciate it.
Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with Creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.