Kate Alfano, CMS Director of Communications

At Clinica Family Health and Wellness, actions taken over the past year tell a devastating story – one that is unfolding across Colorado. Medicaid disenrollments have driven thousands of patients into the ranks of the uninsured, forcing deep cuts to essential services and threatening communities’ access to care. Clinics like Clinica, which has locations in Boulder, Denver, Lafayette, Thornton, Westminster, Nederland and Black Hawk, are lifelines for low-income and rural families and are now on the brink of closure.

“We are a canary in the coal mine, but not the only one,” says Simon Smith, CEO of Clinica Family Health and Wellness. “We are hollowing out primary care and prevention services that keep people healthy and save our system money. The safety net, like the health of the people we serve, is fragile. Insurance status may change, but the needs of the human being do not.”

Before the pandemic, Clinica’s payer mix of patients was 45.7 percent Medicaid and 37.5 percent uninsured. Today, it is 37.5 percent Medicaid and 43.4 percent uninsured. This represents an 8.2 percent drop in Medicaid and a 6 percent rise in the uninsured population from pre-pandemic levels. 

“I know there are questions about what has happened to those who have lost their Medicaid coverage,” Smith says. “At Clinica, it appears that over 70 percent of them are now uninsured. That is thousands and thousands and thousands of newly uninsured patients within our organization.”

Due to lower revenue, Clinica has been forced to eliminate critical programs – from maternal health visits to homeless outreach—while cutting over 100 staff positions across two rounds of layoffs, over 15 percent of their workforce. They have dipped into their limited reserves, executives and high earners have voluntarily cut their pay, and still they are forced to turn away new patients who have nowhere else to go. The safety net is fraying.

Meanwhile, lawmakers need to cut $1 billion in state spending in the next fiscal year to balance a budget that is short pandemic-era federal funding and limited by how much state spending can increase under the Taxpayer’s Bill of Rights (TABOR) cap. Add in increased state spending in the Medicaid program due to an aging population, changes in the amount and mix of services utilized, and underestimating growth, plus uncertainty in continued federal funding, and this convergence means legislators are having tough conversations to prioritize what gets funded and what gets cut.

Physicians, patients and organizations like the Colorado Medical Society are strongly advocating for minimal damage to the health care safety net, fearing that drastic cuts could devastate infrastructure for vulnerable patients and be nearly impossible to rebuild in the future.

How did we get here?

Health First Colorado, Colorado’s Medicaid program, provides free or low-cost health insurance for Colorado children and adults who qualify based on income and household size, around $45,000 annually for a family of four. Child Health Plan Plus (CHP+) provides low-cost health insurance for Colorado children and pregnant women with a slightly higher income than those in Medicaid, around $81,000 for a family of four. Both programs are funded by a federal-state partnership, and the share paid by the federal government for Medicaid increased to 90 percent under the Affordable Care Act when Colorado expanded eligibility to low-income adults. Both programs are administered in our state by the Colorado Department of Health Care Policy and Financing (HCPF).

During the Covid-19 public health emergency (PHE), many Coloradans lost their jobs and their employer-sponsored health insurance, and Health First Colorado rosters swelled by 45 percent, or 550,000 Coloradans. At the height of enrollment, Health First Colorado covered one-third of the state population, according to HCPF. 

Once the PHE ended in May 2023, and with it the federal continuous coverage requirement that guaranteed patients could keep their health coverage, the 1.7 million members of Health First Colorado and CHP+ had to go through a redetermination process to assess if they still qualified for coverage. That 14-month process started in March 2023 with notifications and concluded May 2024. 

Before redetermination began, HCPF estimated that 325,000 Medicaid members would lose eligibility. According to the Kaiser Family Foundation, an independent health policy research organization, by September 2024, 563,000 Medicaid members lost eligibility—a decline of 9 percent—dropping the total enrolled in Medicaid to 1.04 million enrolled in Medicaid. 

And though HCFP’s reported numbers of enrolled Medicaid and CHP+ members have been consistently higher than KFF’s, the agency’s published numbers are close; as of December 2024, HCPF reported enrollment in Health First Colorado was 1.13 million and enrollment in CHP+ was 92,000, for a total of approximately 1.2 million covered lives; still a loss of eligibility for more than 500,000 individuals.

What does it mean to patients and practices when so many lose coverage? 

Save Our Safety Net Colorado – a coalition of health care providers, consumer advocacy groups and other health care organizations including the Colorado Medical Society – is sounding the alarm about negative effects of disenrollment, especially for those are still eligible but not enrolled. 

In an issue brief published in October, the group cited that 65 percent of the more than 500,000 Coloradans who were disenrolled from Medicaid lost coverage due to administrative burdens or procedural reasons such as application processing delays, never receiving and enrollment pack, or onerous enrollment requirements. Some of those have since come back to the program, but others may have been pushed out of the insurance market altogether. The impact for patients and providers is bleak, and the economic implications touch the entire state. 

“Over the last 18 months, over 2,000 of our patients have lost Medicaid coverage,” says Dustin Moyer, CEO of Mountain Family Health Centers, which provides care to Roaring Fork, Colorado and Eagle Valleys. “One year ago, 38 percent of our patients were uninsured; today that figure is 47 percent. In fact, our current payer mix is nearly identical to what it was prior to the state expanding Medicaid through the Affordable Care Act in 2013: 47 percent uninsured and 28 percent Medicaid.” 

Moyer continues: “The decline in Medicaid coverage has led to barriers to care for our patients who need specialty or hospital services, and a significant financial challenge for Mountain Family. We have calculated that our total lost revenue stemming from the 2,000 of our patients who have lost Medicaid is $1.5 million on a $25 million budget.”

To account for the loss of revenue and to ensure they can continue serving their community, in the last 12 months, Mountain Family has eliminated 10 positions and laid off five people, closed two school-based health centers and reduced hours of operation at three others, instituted hiring freezes, and implemented a 3-month suspension of employer retirement contributions.

That brings in the impact of disenrollments on the state economy. The Colorado Health Foundation recently published a study of the positive economic impact of Colorado’s Medicaid expansion under the ACA and negative effects of disenrollment. 

At the high end of a scenario where 504,000 otherwise eligible are disenrolled, the state economy is 0.9 percent smaller with an output loss of $4.7 billion and employment loss of 28,000 jobs. At the low end of the scenario where 100,000 otherwise eligible are disenrolled, the state economy is 0.2 percent smaller with an output loss of just under $1 billion and an employment loss of 5,500.

Phyllis Resnick, PhD, is executive director and lead economist for Colorado Futures Center, and authored the study. “It’s hard to measure things in isolation, but if we could, this is what our models tell us the impact of the disenrollment was: That the economy would be anywhere between 0.2 percent and 0.9 percent smaller depending on that high to low scenario. Then when economies contract, everything related to the economy contracts. Typically, you have higher levels of unemployment. When you have higher levels of unemployment, household earnings go down, and when household earnings go down people spend less in restaurants and retail shops and going skiing and going to the spa and all the other things you spend household income on, and then as a result of that, the tax revenue that’s generated by the state contracts as well.” 

“The reason everyone should care about disenrollment is that even if you’re not directly affected with respect to your health care, because of our state-federal relationship around Medicaid, when we disenroll, we draw down fewer dollars and it does slow the Colorado economy,” Resnick says.

What should happen now? 

The good news is that key Colorado lawmakers on the Joint Budget Committee and Senate and House Health and Human Services committees are educated on these issues, thanks to the advocacy work led by the Colorado Medical Society and made possible by members’ dues investment. 

“When it comes to Medicaid, I think there is a commitment by the vast majority of the legislature to try to preserve and protect the Medicaid program,” Rep. Kyle Brown said in a Jan. 23 panel hosted by the Colorado Health Institute. He chairs the House Health and Human Services Committee. 

“In particular, I think there’s a concern that we would use Medicaid and cutting provider rates or services for folks as a way of filling a hole. We may not have a choice, but I think there is a recognition that Medicaid is usually about life and death for folks, and of all the things that should be on the chopping block, those issues that are literally life and death for people should be towards the bottom.”

Sen. Kyle Mullica, member of the Senate Health and Human Services Committee, and Sen. Barbara Kirkmeyer, member of the Joint Budget Committee, co-wrote an editorial published Nov. 20 in the Denver Post in which they said, “While Colorado has never reached a point where every resident has health insurance, we have done much better in ensuring coverage in recent years. A return to ‘the bad old days’ is unacceptable. In the year ahead, we must make stabilizing our health care safety net and restoring Medicaid coverage for eligible Coloradans our state’s top priority.”

The Colorado Medical Society, as part of Save Our Safety Net, is asking legislators to:

• Resist attempts to cut Medicaid and other behavioral and physical health care safety net funding for individuals who use the public programs for their health coverage and in-home services that allow people with disabilities to live independently in their communities.

• Support funding the Primary Care Fund, an important financing strategy established by the 2004 tobacco tax, at $10 million, and allow gifts, grants and donations to be used to provide additional funding.

• Put greater effort and focus on supporting Coloradans who are eligible but not enrolled in the Medicaid benefits to which they are entitled by expanding points of entry for Medicaid enrollment and supporting additional funding for county enrollment activities.

• Support efforts to require HCPF to create a shared data dashboard cataloging key data points so all interested parties can work together to find solutions.

• Support our calls for a collaborative committee structure to allow consumer advocates, provider groups, health stakeholders and the Polis administration to work together on shared solutions to both the Medicaid disenrollment crisis and the broader issue of the growing number of uninsured Coloradans who need access to health care.

• Seek ways to maximize federal funding and explore innovative options for securing additional revenue, so we can grow state investment in health care and better meet the health care demands of residents.

“Legislators are fired up and eager to help,” says Cody Belzley, an expert on health care policy and Medicaid. “The options are limited given the overall budget challenges, but it’s early in session and we’re working with them to

explore what is possible. We’re still holding out hope that it will be possible to make some investments in the safety net – even if they are ‘down-payments’ or initial steps on a longer-term strategy.”