Health clinics in Colorado are seeing more uninsured patients than they have since the Affordable Care Act took effect a decade ago, and some of their leaders believe the state needs to prepare for a future where more people lack coverage.

Colorado, like most states, has largely completed the process of ending Medicaid coverage for people who are no longer eligible. During the COVID-19 public health emergency, states suspended the process of making recipients prove they still had incomes low enough to qualify.

The majority of the half-million people who lost their Medicaid coverage in Colorado didn’t return the paperwork or otherwise failed to complete the process. So far, the state doesn’t have any data on whether those people have found other insurance.

After the ACA was enacted in 2010, states and the federal government assumed the uninsured rate would continue to fall, and that’s generally what happened, said Phyllis Albritton, managing consultant for the Colorado Safety Net Collaborative, which represents clinics that primarily serve uninsured people and don’t receive federal funding.

That led governments and nonprofits to put fewer resources toward serving the uninsured and to focus more on things like meeting patients’ economic and social needs, she said.

“The grand policy scheme has been, everyone is going to have coverage, so we don’t have to worry about the uninsured,” Albritton said. “We need to accept that there are going to be uninsured people in Colorado.”

Despite public perceptions that everyone can get affordable coverage through the individual marketplace, people often find they can’t pay their out-of-pocket costs if they get sick or hurt, said Bebe Kleinman, CEO of Doctors Carein Littleton, which treats uninsured people and those covered by Medicaid.

She estimated about 20% of her clinic’s patients don’t have insurance — the highest rate since the major provisions of the ACA took effect in 2014.

“It’s been a strange ride from where I thought I was going to shut this place down” because the number of uninsured people was supposed to fall so dramatically under the ACA, Kleinman said.

An analysis of the employer-based insurance market nationwide found the average worker had a deductible of $1,735 for single-person coverage, with people employed by smaller companies generally paying higher deductibles. In contrast, about half of all Americans couldn’t immediately pay a $500 medical bill, and roughly one in five reported they couldn’t pay one even with a payment plan or the ability to borrow money from family, according to the nonprofit group KFF.

Some of the newly uninsured patients may still qualify for Medicaid coverage, but filled out the paperwork wrong or couldn’t find help in a language they understood, Kleinman said. Others are former Medicaid recipients who now earn too much, or new immigrants who don’t know how to purchase insurance, even if they’re eligible and could afford it, she said.

“It becomes so overwhelming that you stay uninsured,” she said.

Other low-income clinics that don’t receive federal funding are also seeing a higher percentage of uninsured patients than they were before the ACA, when about 15% of the population didn’t have coverage, Albritton said. Clinics that do receive that funding, known as federally qualified health centers, also have reported budget struggles as some of their patients fall off Medicaid and become uninsured.

The uninsured rate in Colorado had hovered around 6.5% between the passage of the ACA and the COVID-19 pandemic, before hitting a low of 4.6% in 2023 due to the pandemic freeze on Medicaid disenrollments.

Colorado’s Medicaid unwinding following the end of the public health emergency mostly wrapped up in April, though some people with disabilities have additional time to show they are still eligible. People who lost coverage can regain it through an expedited process if they renew within 90 days, so some could return to Medicaid this summer. Those who’ve gone past the 90-day deadline can still reenroll, but the process is more cumbersome.

As of March, enrollment in Medicaid was down by about 514,000 people from May 2023, or about 29%. At the same time, marketplace enrollment increased by just under 16,000 people, and enrollment in the Child Health Plan Plus was up by more than 38,000. Data isn’t yet available about how many people joined employer-sponsored health plans or became uninsured.

Steps the state could take to help

The state could help offset the increased cost of caring for uninsured people somewhat by finding a more stable revenue source for its primary care fund, which currently gets most of its money from tobacco taxes, Albritton said. As fewer people smoke, that means less money is available to divide among safety net clinics based on the number of appointments they provide to uninsured people, she said.

Health policy wasn’t a focus of this year’s legislative session, though lawmakers did pass a one-time appropriation to aid Denver Health, the state’s only urban safety net hospital.

Legislators also appropriated funding for county and state agencies to staff up, so they can help people renew their Medicaid coverage or find an alternative source of insurance, said Rep. Shannon Bird, a Westminster Democrat and chair of the Joint Budget Committee.

The state already hastaken additional steps, such as automating enrollment for eligible children in Child Health Plan Plus, which has a higher maximum income than Medicaid; trying to make reenrollment as easy as possible; and working with partners to guide people toward insurance options, she said.

Most people probably have an affordable coverage option available, but they may not know what it is or how to enroll in it, Bird said. The budget committee will keep an eye on the problem while meeting between legislative sessions and take steps if it determines agencies need more resources to help people navigate their insurance options, she said.

“My hope is that all of the good work the Department (of Health Care Policy and Financing) is doing will help reverse this trend, and help people who haven’t found an insurance home,” she said.

No one knows yet whether the number of uninsured patients will continue to increase, hold steady or decrease as people learn they lost coverage. Denver Health, which sees a disproportionate percentage of uninsured patients, reported that the increase in patients without coverage has started to level off this spring.

“We have seen a plateau in the increase in uninsured patients, which suggests that most patients who faced disenrollment due to the (public health emergency) unwind have been disenrolled,” an unidentified Denver Health spokesperson said in an email.

The last data from other hospitals is from December. The Colorado Hospital Association reported that about 10% of people presenting to emergency rooms that month didn’t have insurance, compared to an average of about 7% from 2019 through mid-2023.

“The current situation isn’t viable”

Mental health providers alsohave taken a financial hit.

Kiara Kuenzler, president and CEO of Jefferson Center for Mental Health, estimated their uninsured patient population grew about 60%, blowing a more than $7 million hole in their budget for the fiscal year that ends June 30. The center won’t start turning uninsured people away, but with reserves running short, managers will have no choice but to cut back on some services for everyone if nothing changes, she said.

“We just can’t say if or how or when cuts will happen, but the current situation isn’t viable,” Kuenzler said.

In the region that includes Jefferson County, the entity that administers Medicaid projected enrollment would drop by about 16%, or 33,000 people. Instead, it’s down by about 74,000 people, or 37%, Kuenzler said. Some federal and state money helps pay for care to uninsured people, but the funding hasn’t risen nearly as fast as that group’s needs for behavioral health services, she said.

Statewide, community mental health centers face a combined gap of at least $24 million between the funding available for care to the uninsured and the cost of providing that care, said Kara Johnson-Hufford, CEO of the Colorado Behavioral Healthcare Council.

The Colorado Behavioral Health Administration found about $1 million in leftover funding to help, but still leaves a significant budget hole, she said.

The state is rolling out a new Medicaid payment model for community mental health centers that will pay something toward their care to uninsured people, said Cristen Bates, deputy Medicaid director at the Colorado Department of Health Care Policy and Financing. The department also is continuing to work with providers to get their qualifying patients reenrolled, she said.

“Keeping Coloradans covered and getting people covered is a huge priority,” she said.

The Behavioral Health Administration also is working on some additional one-time funding to help tide over providers in “pockets” of the state where an above-average number of people left Medicaid, said Erin Wester, deputy commissioner of systems and programs.

In the near future, the number of people enrolled should start to stabilize, she said.

“We are all working together to try to come up with a solution,” Wester said.

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