Right now, there are nearly 77 million non-elderly people who have health coverage through Medicaid, the federal/state partnership program to provide coverage to disabled Americans, and low-income Americans and their children. Something like 17 million people have enrolled during the COVID-19 pandemic, the result of job loss or long-term disability from the disease. Their coverage is protected under the Families First Coronavirus Response Act, one of the first pandemic response bills which prohibits states from kicking people off the program during the public health emergency.

The problem: That emergency status is now scheduled to expire in April, but it’s uncertain given the short history of this virus and its variants. That’s creating a lot of uncertainty for states, and the very real possibility that 15 million people, including 8.7 million adults and 5.9 million children, will lose their Medicaid coverage this year.

That’s an Urban Institute estimate, which is part of a report from the organization urging coordination between the federal government, state health insurance marketplaces, and Medicaid agencies to make sure these 15 million find other coverage for which they’re eligible.

The Biden administration will allow states up to one year to go through their Medicaid rolls to determine who is still eligible—a normally regular process they haven’t been through in the past two years because of the health emergency. But because of the uncertainty of whether the official public health emergency is going to be extended—and whether the Build Back Better Act and its provision to ease the process will ever pass—states are operating in the dark.

“There’s not a lot of runway here,” Jeff Nelson, director of Utah’s Bureau of Eligibility Policy, told Politico this week. “It’s hard for us to not know what’s going to happen.”

It’s going to be messy barring any federal solution coming either from the Biden administration or Congress. There’s traditionally a lot of churn in Medicaid rolls, as people lose coverage because their income increases and they are no longer eligible, or they fail to provide the documentation required to continue their eligibility when they’re up for review. That could be for any number of reasons—a common one is that Medicaid administrators don’t have current contact information for enrollees, so they don’t get the notice.

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This is likely to be a really big problem with the new pandemic cohort of enrollees who have never had to go through this process before. Millions could be removed from the rolls and not even know it, nor get the information that could help them find new coverage in the marketplaces. “That’s really one of the big risks, that people will be eligible but become unenrolled just because they don’t get the message and don’t know how to continue their coverage and are just out of the habit, quite honestly, of doing renewals and redeterminations after almost two years,” Suzanne Bierman, administrator of Nevada’s Medicaid program, told Politico.

There’s also the danger that some states—the Republican ones—see this as an opportunity to just cut people loose and provide them no assistance in finding other coverage. “What we have seen historically is that so many eligible people get caught up in the chaos of this, of states not doing good ex parte [renewals], of not updating addresses, not leveraging SNAP information for addresses or income or other things, relying on paper-based mail instead of any effort to phone calls or text messages or other things,” said Jennifer Wagener, director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities.

“Most of us go to sleep at night thinking about this and what we can do the next day around this,” said Daniel Tsai, director of the Center for Medicaid and CHIP Services. He told Politico the level of effort on this issue in the department as “unprecedented,” adding, “We are pulling out all the stops.”

“We are highly cognizant that states kind of need to know an end date to get things moving,” Tsai said. “Our message has been, ‘We should just plan for that coming as soon as possible.’ Not to say it will be … but the answer is, ‘Do not sit and wait.’”

States, however, know that they’re going to have to devote substantial resources to both conducting the reviews and making sure that people don’t fall through the cracks. They, like everyone else, are at the mercy of this virus and all its variants—we’re playing on its timeline, though it seems likely at this point that the public health emergency will officially end in April, and with it automatic Medicaid eligibility for these folks.

Congress could help. They could either pass Build Back Better or pass separate legislation to do what that provision would: phase out the continuous enrollment requirement established by the public health emergency beginning April 1, 2022 along with rules tying disenrolling people to a phased down enhanced federal match rates.  

The version for the BBB that the  House passed provided a path to coverage for the people in the Medicaid coverage gap—many of this population—by allowing for them to purchase subsidized coverage under Obamacare marketplaces. It also requires that states provide a full 12 months of Medicaid coverage for postpartum people and infants, to make sure that population doesn’t fall out of coverage.

Between February 2020 and June 2021, Medicaid enrollment in West Virginia increased from 489,000 people to 587,000. That means 80,000 people in that state are in danger of losing coverage and potentially not even knowing it, largely thanks to their senator, Joe Manchin, who is single-handedly stopping the legislation that would fix it.