Medicaid Coverage Disruptions Among Children Enrolled in North Carolina Medicaid From 2016 to 2018

Rushina Cholera,Alexander Breskin,Nuvan Rathnayaka,Suzanne Landi,M Alan Brookhart,David Anderson,Janet Prvu Bettger,Bethany Diprete,Sudha R Raman,Bradley G Hammill,Charlene A Wong,Rebecca G Whitaker,Catherine Wiener

doi:10.1001/jamahealthforum.2021.4283

Abstract

Brief disruptions in insurance coverage among eligible participants are associated with poorer health outcomes for children. To describe factors associated with coverage disruptions among children enrolled in North Carolina Medicaid from 2016 to 2018 and estimate the outcome of preventing such disruptions on medical expenditures. This was a retrospective cohort study using North Carolina Medicaid claims data. All enrolled individuals were aged 1 to 20 years on January 1, 2016, and with 30 days of prior continuous enrollment. Children were observed from January 1, 2016, until December 31, 2018. Analyses were conducted from June 2020 through December 2020. Risk of Medicaid coverage disruptions of 1 to less than 12 months was assessed. Among children who disenrolled from Medicaid for 30 or more days, the risk of reenrollment within 1 to 6 months and 7 to 11 months was assessed. An inverse probability of censoring weights method was then used to estimate the outcome of an intervention to reduce coverage disruptions through preventing disenrollment on per member per month (PMPM) cost. The study population included 831 173 Medicaid beneficiaries aged 1 to 5 years (23%), 6 to 17 years (68%), and 18 to 20 years (9%); 35% were Black, 44% were White, and 14% were Hispanic/Latinx. Among those with a first disenrollment (n = 214 401, 26%), the risk of reenrollment within 6 months and 7 to 11 months was 19% and 7%, respectively. Risk of coverage disruption was higher for Black children (hazard ratio [HR], 1.21; 95% CI, 1.18-1.24), children of other races (Asian, American Indian, Hawaiian or Pacific Islander, multiple races, or unreported; HR, 1.37; 95% CI, 1.33-1.40), and Latinx children (HR, 1.65; 95% CI, 1.60-1.70) compared with White children. Risk of coverage disruption was also higher for children with higher medical complexity (HR, 1.15; 95% CI, 1.12-1.19). The risk of coverage disruption was lower for children living in counties with the highest unemployment rates (HR, 0.89; 95% CI, 0.85-0.94), and comparisons between county-level measures of child poverty and graduation rates showed little or no difference. The estimated PMPM cost for the full population under a scenario in which all medical costs were included was $125.73. Estimated PMPM cost for the full cohort in a counterfactual scenario in which disenrollment was prevented was slightly lower ($122.14). Across all subgroups, estimated PMPM costs were modestly lower ($2-$8) in the scenario in which disenrollment was prevented. In this cohort study, the risk of Medicaid coverage disruption was high, with many eligible children in historically marginalized communities continuing to experience unstable enrollment. In addition to improving health outcomes, preventing coverage gaps through policies that decrease disenrollment may also reduce Medicaid costs.

Highlights

Disruptions in insurance coverage are associated with reduced health care access and unmet health care needs for children.[1,2,3,4] Children with even short periods of uninsurance experience delays in care, are less likely to receive preventive care, and are more likely to seek emergency care for ambulatory conditions.[5,6,7,8] Policy changes following the Children’s Health Insurance Program Reauthorization Act of 2009 and the Affordable Care Act (ACA) in 2014 improved enrollment and retention in Medicaid among children
Risk of coverage disruption was higher for Black children, children of other races (Asian, American Indian, Hawaiian or Pacific Islander, multiple races, or unreported; HR, 1.37; 95% CI, 1.33-1.40), and Latinx children (HR, 1.65; 95% CI, 1.60-1.70) compared with White children
We examined coverage disruptions of 2 durations, 1 to 6 months and 7 to months, based on the assumptions that (1) brief coverage gaps of less than 1 month were likely due to administrative errors that would not have affected enrollment status, (2) that children who reenrolled in Medicaid within 6 months of coverage loss were likely eligible during the period of disenrollment, and (3) that those who reenrolled within 7 to less than months were possibly eligible for coverage while disenrolled.[13]

Summary

Introduction

Disruptions in insurance coverage are associated with reduced health care access and unmet health care needs for children.[1,2,3,4] Children with even short periods of uninsurance experience delays in care, are less likely to receive preventive care, and are more likely to seek emergency care for ambulatory conditions.[5,6,7,8] Policy changes following the Children’s Health Insurance Program Reauthorization Act of 2009 and the Affordable Care Act (ACA) in 2014 improved enrollment and retention in Medicaid among children. In recent years, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) decreased by more than a million children, partly thought to be due to state-level policies that increase coverage disruptions for eligible children.[9,10] More than 30% of children eligible for Medicaid or CHIP still experience insurance coverage gaps yearly, with substantial variation among states.[11,12,13] Importantly, insurance coverage gaps are more common among children living in rural areas and those experiencing social risks, including lower income, housing instability, or fears of immigration enforcement.[5,7,11,14,15,16,17]

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Discussion

Conclusion