Medicaid Unwinding: Coverage Gaps and Access Challenges

According to a Harvard T.H. Chan School of Public Health study, one in eight low-income adults who had been enrolled in Medicaid at some point since March 2020 reported not having Medicaid coverage by late 2023, with nearly half of that pool reporting being uninsured at the moment. The survey participants were low-income adults in the states of Arkansas, Kentucky, Louisiana, and Texas.

From September to November 2023, or around six months after “Medicaid unwinding” (the process by which states rechecked Medicaid users’ eligibility after the expiration of COVID-19-era coverage safeguards), the researchers conducted the study.

“We know from government statistics that, of the more than 90 million people whose health coverage was in jeopardy amid Medicaid unwinding, more than 23 million were removed from the program. But those statistics don’t tell us what happened to those people, or why they lost coverage,” said lead author Adrianna McIntyre, assistant professor of health policy and politics.

“Our study is one of the first to help answer those outstanding questions, using completely new data from an original multi-state survey.”

The research is released in JAMA Health Forum on June 29.

In those four states, 2,210 persons between the ages of 19 and 64 who had incomes that were at or below 138% of the federal poverty level in 2022 were surveyed by the researchers.

Participants were asked if they had ever been enrolled in Medicaid, either for themselves or for their dependents, since states halted Medicaid disenrollment in response to the COVID-19 federal public health emergency in March 2020. Along with their demographic data, they were also questioned about their capacity to access care, health insurance, and current status.

The majority of survey participants (71%) stated that they have enrolled in Medicaid at some point since March 2020, either for themselves or a dependent.

12.5% of adult responders who were enrolled in Medicaid said they had been withdrawn by fall of 2023. Adult disenrollment rates by state varied, with 7% in Kentucky, 8% in Louisiana, 15% in Texas, and 16% in Arkansas. Although a sizable portion of people disenrolled reported having coverage gaps, 52% of them had found another insurance source.

Of those who were disenrolled, 48% still did not have health insurance. The likelihood of being uninsured was higher for women than for males, and enrollment was notably higher among those who were younger, lived in rural areas, and/or were employed. For dependent children, the stated disenrollment rate was, on average, somewhat lower (5.4%).

The study also discovered that, in comparison to people who kept their Medicaid coverage, individuals who had been disenrolled had much less access to medical treatment. Disenrolled individuals claimed that care was more expensive than the year before (47% against 22%), that they had missed or delayed medication doses (45% versus 27%), and that they had not had an annual physical in the preceding year (57% versus 34%).

“In prior research, even brief coverage gaps have been associated with care disruptions and negative health outcomes,” said McIntyre.

“Our findings suggest that state and federal policymakers should pursue policies to mitigate adverse outcomes associated with coverage disruptions—not just during the Medicaid unwinding, but in the years to come, as issues related to eligibility redeterminations and continuity of coverage will remain relevant in Medicaid.”

The survey sample was restricted to citizens of four states with lower incomes, and there were significant differences in the ways that the states approached unwinding, the researchers said. As a result, the study’s conclusions may not be as generalizable as they could be.

For more information: Coverage and Access Changes During Medicaid Unwinding, JAMA Health Forum, https://dx.doi.org/10.1001/jamahealthforum.2024.2193