Arkansas’ removal of thousands of children from Medicaid coverage this year has raised concerns with the U.S. Department of Health and Human Services, according to a Monday letter from the department secretary to Gov. Sarah Huckabee Sanders.

In Arkansas, 78,506 fewer children were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) in September than in March of this year, an 18% enrollment decrease, according to HHS data.

Much of the decline resulted from the Arkansas Department of Human Services’ six-month review of the eligibility of Medicaid recipients whose coverage was extended for three years due to the COVID-19 pandemic. Roughly 420,000 Arkansans retained coverage during that period even if they no longer qualified for benefits because of income or other eligibility limits.

The nationwide Public Health Emergency (PHE) enacted at the start of the pandemic in 2020 ended May 11. In April, DHS began “unwinding” the extension by disenrolling clients the agency considered ineligible.

Some clients made too much money to qualify for Medicaid anymore and others asked to be disenrolled, according to the monthly data reports DHS published.

By Sept. 30, more than 184,500 Arkansans lost coverage because they did not provide necessary eligibility information.

Arkansas Democrats criticize DHS’ handling of post-pandemic Medicaid “unwinding”

In some cases, the beneficiaries likely declined to submit renewal paperwork because they no longer qualified for coverage, state Medicaid officials have said. But advocates have also cautioned that some still-eligible beneficiaries likely lost coverage because they never received proper notification or encountered problems when trying to return renewal information. 

About 35% of Arkansas’ disenrolled Medicaid clients from April 1 to Sept. 30 were children, according to data collected by health policy researcher KFF.

Almost 40 million children nationwide receive Medicaid or CHIP benefits, federal HHS Secretary Xavier Becerra wrote in his letter to Sanders. He said he is “deeply alarmed” by Arkansas’ decline in children’s enrollment in these programs.

“Children are more likely than their parents to qualify for Medicaid due to higher income eligibility thresholds for children in Medicaid and CHIP,” Becerra wrote. “This means that as children go through the renewals process, many children should still be Medicaid or CHIP eligible and should not be getting disenrolled.”

The letter included a list of recommendations from HHS to reach families with children eligible for re-enrollment in CHIP or ARKids First, the state’s Medicaid program for children.

“I urge you to ensure that no child in your state who still meets eligibility criteria for Medicaid or CHIP loses their health coverage due to ‘red tape’ or other avoidable reasons,” Becerra wrote.

Arkansas leaders “should jump at the chance to adopt these [suggested] changes and protect children’s health as much as possible,” Arkansas Advocates for Children and Families Health Policy Director Camille Richoux said in a statement.

“For example, Arkansas could use the list of families who have TANF benefits to confirm that a child should still have ARKids coverage,” Richoux said, referring to federal Temporary Assistance for Needy Families benefits. “That would make it easier for children who we know are eligible to keep their coverage.”

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Data and responses

Arkansas had both the fifth-highest number and percentage of children disenrolled from coverage, according to HHS data. Texas, Florida, Georgia and Ohio all had higher numbers of disenrolled children; South Dakota, Idaho, New Hampshire and Montana all had higher percentages.

All nine states received letters from Becerra on Monday because they accounted for roughly 60% of the nationwide decline in children’s enrollment in Medicaid and CHIP from March to September 2023, according to a news release from HHS.

Sanders took issue with Becerra’s letter on X (formerly Twitter) Monday afternoon, noting that all nine states that received letters have Republican governors.

“The failing Biden admin sent letters to GOP led states in a politically motivated PR stunt, accusing us of restricting Medicaid access. That’s false,” Sanders wrote. “During the unwinding process mandated by federal law, the Biden admin sent letters to certain states to pause their unwinding, but Arkansas was never one of them.”

‘Worse Than People Can Imagine’: Medicaid ‘Unwinding’ Breeds Chaos in States

The previous letters Sanders mentioned were from Daniel Tsai, director of the Center for Medicaid and the Children’s Health Insurance Program (CHIP) within the federal Centers for Medicare and Medicaid Services. In August, Tsai asked some states to restore coverage to Medicaid clients who were disenrolled for procedural reasons.

DHS communications chief Gavin Lesnick said at the time that this request did not apply to Arkansas. Lesnick was unavailable for comment Monday on Becerra’s letter.

Arkansas drew national attention this year for its number of procedural disenrollments and for planning to complete the unwinding in only six months, shorter than any other state’s unwinding plan, as required by a 2021 state law.

Medicaid client advocates held several protests throughout the unwinding. One of their complaints about Arkansas’ administration of Medicaid was that they had difficulties ensuring DHS had accurately recorded or updated their income and contact information.

Arkansas Medicaid recipients share concerns with federal and state officials

More than 1 million Arkansans — about a third of the state’s population — were receiving Medicaid benefits at the start of April. That number was 868,059 as of Oct. 1, Lesnick said.

As of Dec. 1, that number had increased to 884,951, DHS Secretary Kristi Putnam told the Arkansas Legislative Council on Friday.

Putnam said many Medicaid disenrollments during the unwinding resulted from Arkansans not filling out renewal forms because they knew they were no longer eligible. She also said decreasing unemployment rates and increases to the state’s minimum wage likely resulted in former Medicaid enrollees earning enough income to no longer be eligible for coverage.

“In cases where we found they didn’t receive a notice, or maybe didn’t receive it timely [enough], we’ve been able to work through cases where there were issues and reinstate people who were still eligible,” Putnam said.