Medicaid Disenrollment Research Articles

Retention in care and antiretroviral therapy adherence among Medicaid beneficiaries with HIV, 2001–2015

ABSTRACT Disparities in HIV care by socioeconomic status, place of residence, and race/ethnicity prevent progress toward epidemic control. No study has comprehensively characterized the HIV care cascade among people with HIV enrolled in Medicaid – an insurance source for low-income individuals in the US. We analyzed data from 246,127 people with HIV enrolled in Medicaid 2001–2015, aged 18–64, living in 14 US states. We estimated the monthly prevalence of four steps of the care cascade: retained in care/adherent to ART; retained/not adherent; not retained/adherent; not retained/not adherent. Beneficiaries were retained in care if they had an outpatient care encounter every six months. Adherence was based on medication possession ratio. We estimated prevalence using a non-parametric multi-state approach, accounting for death as a competing event and for Medicaid disenrollment using inverse probability of censoring weights. Across 2001–2015, the proportion of beneficiaries with HIV who were retained/ART adherent increased, overall and in all subgroups. By 2015, approximately half of beneficiaries were retained in care, and 42% of beneficiaries were ART adherent. We saw meaningful differences by race/ethnicity and region. Our work highlights an important disparity in the HIV care cascade by insurance status during this time period.

Racial and Ethnic Disparities in Medicaid Disenrollment After the End of the COVID-19 Public Health Emergency

This survey study reports the proportions of and reasons for Medicaid coverage loss among racially and ethnically minoritized individuals.

TennCare Disenrollment Led To Increased Eviction Filings And Evictions In Tennessee Relative To Other Southern States.

Previous research suggests that enrolling in Medicaid reduces evictions by improving health and providing financial protection. However, previous studies have not examined whether the loss of Medicaid affects eviction outcomes. We analyzed eviction filings and completed evictions after a large, mandatory Medicaid disenrollment in Tennessee in 2005. We conducted a difference-in-differences analysis using data from the Eviction Lab at Princeton University and found that relative to other southern states, the TennCare disenrollment led to a 27.6percent greater increase in the average annual number of eviction filings at the county level during the period 2005-09 and a 24.5percent greater increase in the average annual number of completed evictions at the county level during that same period. Our findings have implications for the housing stability of Medicaid recipients today, many of whom are being disenrolled because of the unwinding of the Medicaid continuous enrollment provision that is occurring across the country. To protect housing stability for people disenrolled from Medicaid, policy makers may wish to consider new initiatives aimed at preventing an increase in eviction.

Use of in-network insurance benefits is critical for improving retention in telehealth-based buprenorphine treatment.

An empiric evidence base is lacking regarding the relationship between insurance status, payment source, and outcomes among patients with opioid use disorder (OUD) on telehealth platforms. Such information gaps may lead to unintended impacts of policy changes. Following the phase-out of the COVID-19 Public Health Emergency, states were allowed to redetermine Medicaid eligibility and disenroll individuals. Yet, financial barriers remain a common and significant hurdle for patients with OUD and are associated with worse outcomes. We studied 3842 patients entering care in 2022 at Ophelia Health, one of the nation's largest OUD telehealth companies, to assess associations between insurance status and 6-month retention. In multivariable analyses, in-network patients who could use insurance benefits were more likely to be retained compared with cash-pay patients (adjusted risk ratio [aRR]: 1.50; 95% CI: 1.40-1.62; P < .001). Among a subsample of 882 patients for whom more detailed insurance data were available (due to phased-in electronic health record updates), in-network patients were also more likely to be retained at 6 months compared with insured, yet out-of-network patients (aRR: 1.86; 95% CI: 1.54-2.23; P < .001). Findings show that insurance status, and specifically the use of in-network benefits, is associated with superior retention and suggest that Medicaid disenrollment and insurance plan hesitation to engage with telehealth providers may undermine the nation's response to the opioid crisis.

Unwinding of Continuous Medicaid Coverage Among Patients at Community Health Centers

This retrospective cohort study uses data from the Accelerating Data Value Across a National Community Health Center Network to assess patterns of Medicaid disenrollment during the first 6 months after the end of continuous enrollment.

Pandemic‐era changes to medicaid enrollment and funding: Implications for future policy and research

AbstractThe COVID‐19 public health emergency led to federal legislation that changed the landscape of Medicaid coverage for low‐income people in the United States. Policy responses led to a surge in Medicaid caseloads due to new rules preventing Medicaid disenrollment, and total Medicaid enrollment increased more from 2020 to 2023 than the net increase in insurance coverage from 2013 to 2017 following the Affordable Care Act's implementation. It is crucial for scholars and practitioners to understand the implications of this continuous coverage policy and its 2023–2024 unwinding. This paper provides an overview of Medicaid enrollment, renewal, and funding policies, highlighting how policy changed during and immediately following the acute phase of the pandemic; describes enrollment increases and their composition; reviews relevant literature; and identifies key areas for research. By examining this unprecedented period in Medicaid, we can inform future policy decisions and optimize safety net programs to be effective under a broad set of circumstances.

Insurance Coverage Transitions After Disenrollment From Medicaid in Minnesota

This cohort study examines insurance transitions after Medicaid disenrollment for Minnesota residents aged 64 years or younger.

Association Between Medicaid Waivers and Medicaid Disenrollment Among Autistic Adolescents During the Transition to Adulthood

This cohort study examines whether Medicaid waivers were associated with a reduced risk of Medicaid disenrollment among autistic adolescents who are transitioning to adulthood.

Duration and Continuity of Medicaid Enrollment Before the COVID-19 Pandemic

COVID-19 relief legislation created a temporary moratorium on Medicaid disenrollment, but when the public health emergency ends, states will begin to "unwind" Medicaid enrollment. Prepandemic data shed light on factors that can affect Medicaid coverage stability. To assess factors associated with the duration and continuity of Medicaid enrollment. In this cross-sectional analyses of a Medicaid data set for 2016 that was released by the Agency for Healthcare Research and Quality in June of 2022, we analyze a nationally representative data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016. We focus on 22 million nondisabled, nonelderly adults for this analysis. The data were analyzed between July and September of 2022. The main outcomes were the average months of Medicaid enrollment in 2016 and the probability of churning, defined as a break in coverage between 2 periods of enrollment during the calendar year. We compared these outcomes by eligibility category, state, demographic characteristics, and key Medicaid policies, including whether the state expanded Medicaid and whether it used ex parte reviews (automated reviews of other administrative data to reduce renewal paperwork burdens). In this cross-sectional analysis, we analyze a nationally representative Medicaid data set of 5.7 million persons, weighted to represent 70 million Medicaid beneficiaries in 2016, released by the Agency for Healthcare Research and Quality in June of 2022. The analysis focused on nonelderly, nondisabled adults (aged 18-64 years) with a weighted population size of 22.7 million, of which 18.4% were Black, 19.2% were Latino, 39.5% were White, 7.3% were other/Asian/Native American, and 15.5% had unknown race. Multivariable regression analysis indicated that those living in states that expanded Medicaid but did not use ex parte reviews had longer average duration (0.31 months longer; 95% CI, 0.03-0.59) and lower risk of churning(odds ratio [OR], .40; 95% CI, 0.39-0.40), whereas those living in nonexpansion states that used ex parte reviews had lower odds of churning (OR, .68; 95% CI, 0.66-0.70) but also had shorter average duration (3.1 months shorter; 95% CI, -3.4 to -2.8). Those living in expansion states that used ex parte reviews also had reduced churning (OR, .83; 95% CI, 0.82-0.85). The average duration varied widely by state, even after adjustments for demographic and state policy factors. If state Medicaid programs revert to prepandemic policies after the temporary moratorium ends, Medicaid coverage, particularly for nondisabled, nonelderly adults, is likely to become less stable again. Medicaid expansions are associated with improved continuity, but ex parte review may have a more complex role.

The Politics of Welfare Retrenchment: Evidence from Mass Medicaid Disenrollment in Two States

AbstractIn 2005, Missouri and Tennessee tightened eligibility for their public health insurance programs, resulting in widespread coverage losses. Leveraging county-level variation in subsequent disenrollment, I show that voters in Tennessee punished the incumbent governor for the Medicaid cuts. In Missouri, by contrast, disenrollment had no impact on the subsequent gubernatorial election but did increase support for Democrats in 2006 state legislative elections, possibly due to the strategic entry and exit of candidates. In both states, the loss of Medicaid coverage was associated with lower support for Democratic presidential candidates, although these declines appear part of a longer-term trend that preceded the coverage loss. The results speak to the potential political costs of welfare spending cuts and the electoral consequences of reducing income-targeted social programs.

Uptake of hepatitis C virus treatment in a multi-state Medicaid population, 2013-2017.

To examine trends in the direct acting antiviral (DAA) uptake in a multi-state Medicaid population with hepatitis C virus (HCV) prior to and after ledipasvir/sofosbuvir (LDV/SOF) approval and changes in prior authorization (PA) requirements. Analyses utilized enrollment, medical, and pharmacy claims in four states, December 2013-December 2017. An interrupted time series examined trends in uptake (1+ claim for a DAA) before and after two events: LDV/SOV approval (October 2014) and lifting of PA requirements for 40% of members (July 2016). Analyses were also performed in subgroups defined by the number and dates of change in PA requirements in members' Medicaid plans. Members aged 18-64 years with an ICD code for HCV were included in the sample from diagnosis date until treatment initiation or Medicaid disenrollment. The annual sample size ranged from 38,302 to 45,005 with approximately 30% ages 18-34 years and 40% female. In December 2013, 0.08% was treated, rising to 0.74% in December 2017 (p < 0.001). Uptake increased from 0.34%/month in October 2014 to 0.70%/month after LDV/SOF approval, (p < 0.001), and increased relative to the pre-LDV/SOV trend through June 2016 (p=0.04). Uptake increased to 1.18%/month after PA change, (p < 0.001) and remained flat through 2017 (p=0.64). Cumulatively, 20.1% were treated by December 2017. In plans with few/no requirements through 2017, uptake increased to 1.19%/month after LDV/SOF approval (p < 0.001) and remained flat through 2017 (p=0.11), with 22.2% cumulatively treated. Among plans that lifted PA requirements from three to zero in mid-2016, uptake did not increase after LDV/SOF approval (p=0.36) but did increase to 1.41%/month (p < 0.001) after PA change, with 18.1% cumulatively treated. HCV Treatment increased through 2017. LDV/SOF approval and lifting PA requirements led to an increase in uptake followed by flat monthly utilization. Cumulative uptake was higher in plans with few/no PA requirements relative to those with three requirements through mid-2016.

Eviction, Healthcare Utilization, and Disenrollment Among New York City Medicaid Patients

Although growing evidence links residential evictions to health, little work has examined connections between eviction and healthcare utilization or access. In this study, eviction records are linked to Medicaid claims to estimate short-term associations between eviction and healthcare utilization, as well as Medicaid disenrollment. New York City eviction records from 2017 were linked to New York State Medicaid claims, with 1,300 evicted patients matched to 261,855 non-evicted patients with similar past healthcare utilization, demographics, and neighborhoods. Outcomes included patients' number of acute and ambulatory care visits, healthcare spending, Medicaid disenrollment, and pharmaceutical prescription fills during 6 months of follow-up. Coarsened exact matching was used to strengthen causal inference in observational data. Weighted generalized linear models were then fit, including censoring weights. Analyses were conducted in 2019-2021. Eviction was associated with 63% higher odds of losing Medicaid coverage (95% CI=1.38, 1.92, p<0.001), fewer pharmaceutical prescription fills (incidence rate ratio=0.68, 95% CI=0.52, 0.88, p=0.004), and lower odds of generating any healthcare spending (OR=0.72, 95% CI=0.61, 0.85, p<0.001). However, among patients who generated any spending, average spending was 20% higher for those evicted (95% CI=1.03, 1.40, p=0.017), such that evicted patients generated more spending on balance. Marginally significant estimates suggested associations with increased acute, and decreased ambulatory, care visits. Results suggest that eviction drives increased healthcare spending while disrupting healthcare access. Given previous research that Medicaid expansion lowered eviction rates, eviction and Medicaid disenrollment may operate cyclically, accumulating disadvantage. Preventing evictions may improve access to care and lower Medicaid costs.

Medicaid Disruption Among Transition-Age Youth on the Autism Spectrum.

Enrollment in Medicaid facilitates access to needed services among transition-age youth on the autism spectrum and youth with intellectual disability (ID). There are long-standing programs to ensure that individuals with ID remain enrolled as they age; similar programs for autistic youth are newer, not as widespread, and may not be as effective. We compared Medicaid disenrollment and re-enrollment between transition-age youth on the autism spectrum, youth with ID, and youth with both diagnoses using a national claims-based prospective cohort study from 2008 through 2012. Autistic youth were most likely to disenroll and least likely to re-enroll. Disenrollment peaked for all three groups at ages 19 and 21. Transition-age youth on the autism spectrum experience more disruptions in access to Medicaid-reimbursed services than youth with ID. More equitable Medicaid enrollment options for autistic individuals are needed to ensure their access to critical health care as they age.

Work Requirements and Medicaid Disenrollment in Arkansas, Kentucky, Louisiana, and Texas, 2018.

Objectives. To identify risk factors for Medicaid disenrollment after the implementation of Arkansas's work requirements.Methods. Using a 2018 telephone survey of 1208 low-income adults aged 30 to 49 years in Arkansas (expansion state with work requirements implemented in June 2018), Kentucky (expansion state with proposed work requirements blocked by courts), Louisiana (expansion state without work requirements), and Texas (nonexpansion state), we assessed Medicaid disenrollment rates among the age group targeted by Arkansas's policy.Results. The Medicaid disenrollment rate was highest in Texas (12.8%), followed by Arkansas (10.5%), Kentucky (5.8%), and Louisiana (2.8%). Over half of those who disenrolled in Texas and Arkansas became uninsured, compared with less than a quarter in Kentucky and Louisiana. In multivariate models, Arkansas had significantly higher disenrollment compared with the 3 comparison states; men and non-Hispanic Whites experienced higher disenrollment than women and racial minorities. In Arkansas, having a chronic condition was associated with higher disenrollment.Conclusions. As states debate work requirements and Medicaid reforms, our findings provide insights for policymakers about which populations may be most vulnerable to losing Medicaid coverage.

Clinical Outcomes and Healthcare Utilization in Patients with Sickle Cell Disease: A Nationwide Cohort Study of Medicaid Beneficiaries

Introduction: There is limited contemporary evidence on clinical outcomes and healthcare use in sickle-cell disease (SCD) patients enrolled in US Medicaid. We aimed to provide contemporary estimates for rates of vaso-occlusive crises (VOC), mortality, and healthcare resource utilization (HRU) in SCD patients enrolled in US Medicaid. Methods: We conducted a cohort study using nationwide Medicaid insurance claims data (2000-2013). Patients were included based on ≥1 inpatient or ≥2 outpatient HbSS SCD diagnosis claims after 365 days continuous enrollment in Medicaid (or continuous eligibility since birth if age at diagnosis is &amp;lt;1 year). Patients were followed until Medicaid disenrollment, death, bone marrow transplant, or end of data availability (December 31, 2013). Outcomes included frequency of VOCs, event rates of HRU including emergency department (ED) visits, hospitalizations, outpatient visits, and blood transfusions, and all-cause mortality during the follow-up period. All outcomes were reported as annualized event rates (with 95% confidence intervals). VOCs were stratified by age-group (&amp;lt;1, 2-6, 7-12, 13-18, 19-35, 35+ years), VOCs at baseline (&amp;lt;2, 2-4, &amp;gt;=5), race (African American or not), and sex. The impact of VOCs on the risk of mortality was analyzed using an extended multivariable Cox model with VOCs modeled as time-varying and updated annually. Results: A total of 44,033 SCD patients were included in the analysis; 47% were female, 82% were African American, and a mean (SD) age of 15.7 (13.6). The average VOC rate was 3.71 (95% CI: 3.70-3.72) VOCs per person-year over an average follow-up period of 4.3 years. The rate of VOCs was substantially higher among patients aged 19-35 years and those with a higher VOC frequency at baseline (Table 1). Overall, the event rates (95%CI) per person year for other HRU outcomes were: 2.97 (2.97-2.98) ED visits, 2.39 (2.38-2.40) hospitalizations, 5.80 (5.79-5.81) outpatient visits, and 0.91 (95%CI: 0.90-0.91) blood transfusions. The mortality rate was 1.13 (95%CI: 1.08-1.17) events per 100 person-years overall, with the highest rate being 4.91 (95%CI: 4.58-5.25) events per 100 person-years among patients ≥ 35 years of age. Higher VOC burden in the preceding year was associated with an increased risk mortality: 2-4 VOC vs. 0 or 1 VOC: Hazard Ratio (HR)=1.36 (95%CI: 1.21-1.52); ≥ 5 VOC: HR= 1.56 (95%CI: 1.39-1.75). Conclusion: The burden of SCD in US Medicaid enrollees is substantial, especially during early adulthood, with markedly high rates of VOCs, mortality, and healthcare utilization. A higher VOC rate in the preceding year was associated with an increased risk of mortality suggesting a need for careful management of SCD patients with higher VOC burden. Table 1. Annualized rates of vaso-occlusive crises (VOC) among sickle cell disease patients enrolled in Medicaid. VOC, vaso-occlusive crises; CI, confidence interval. Table 1 Disclosures Desai: Merck: Research Funding; Bayer: Research Funding. Globe:Vertex Pharmaceuticals Incorporated: Employment. McKerracher:CRISPR Therapeutics: Employment. Mutebi:Vertex Pharmaceuticals Incorporated: Employment. Bohn:Bohn Epidemiology: Equity Ownership; Vertex Pharmaceuticals Inc: Consultancy. Achebe:Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees; Pharmacosmos: Membership on an entity's Board of Directors or advisory committees; Fulcrum Therapeutics: Membership on an entity's Board of Directors or advisory committees; Bluebird Bio: Membership on an entity's Board of Directors or advisory committees. Schneeweiss:Genentech: Research Funding; Boehringer Ingelheim: Research Funding; Aetion, Inc.: Consultancy, Equity Ownership; Whiscon LLC: Consultancy.

Effect of Medicaid Disenrollment on Health Care Utilization Among Adults With Mental Health Disorders.

Medicaid is an important source of insurance coverage for those with mental health (MH) disorders in the United States. Although disruptions in Medicaid coverage are common, little is known about the dynamic relationship between Medicaid disenrollment and MH care utilization. We estimated changes in all-cause and MH-related health care use post Medicaid disenrollment among a nationwide cohort of adults with MH disorders. We identified 8841 persons (197,630 person-months) ages 18-64 with MH disorders and Medicaid coverage from Panels 4 to 19 Medical Expenditure Panel Survey. Using a quasi-experimental design and propensity weighting, we estimated logit models examining changes in service utilization per-person-per-month. We used a "post" indicator to estimate average differences in service use postdisenrollment (vs. those with continuous Medicaid coverage) and a count variable measuring total months since coverage loss to estimate changes over time. All-cause outpatient visits, MH-related outpatient visits, and acute care visits. Becoming uninsured after Medicaid disenrollment was associated with average reductions of 52% [-14.75 percentage-points, 95% confidence interval (CI): -17.59, -11.91] in the likelihood of receiving any outpatient service, 35% (-2.23 percentage-points, 95% CI: -3.71, -0.75) in the likelihood of receiving any MH-related outpatient service, and 52% (-2.44 percentage-points; 95% CI: -3.35, -1.52) in the likelihood of receiving any acute service in a month. Health care use declined the most in the month immediately postdisenrollment, and declines continued over the next half-year (while uninsured). Insurance loss after disenrollment from Medicaid led to a persistent disruption in the receipt of health care services for beneficiaries with MH disorders.

Association Of State Policies With Medicaid Disenrollment Among Low-Income Medicare Beneficiaries.

For some low-income Medicare beneficiaries, Medicaid provides financial protection against Medicare's out-of-pocket costs, but many Medicare beneficiaries who qualify for Medicaid are not continuously enrolled. We examined Medicaid disenrollment among fee-for-service Medicare beneficiaries and the relationship between disenrollment and state policies. In the period 2012-16, 18.2percent of Medicare beneficiaries who received full or partial Medicaid disenrolled for reasons other than death. More than 50percent of Medicare beneficiaries who remained without Medicaid one year after disenrolling continued to receive low-income subsidies for Medicare Part D coverage with eligibility requirements similar to those of Medicaid. Among Medicare beneficiaries with continuous Part D subsidies, the rate of Medicaid disenrollment was 24percent lower in states that automatically enrolled recipients of the federal Supplemental Security Income program in full Medicaid, 33percent lower in states with more generous provider payment policies, and 37percent lower in states with less restrictive asset limits for partial Medicaid. Policies that make it easier for people to maintain Medicaid eligibility and that enhance access to care in Medicaid via higher provider reimbursements may reduce disenrollment.

Purged from the Rolls: A Study of Medicaid Disenrollment in Iowa

Purpose: To describe the impact of disenrollment from Medicaid because of failure to pay premiums as part of Iowa's Medicaid program's personal responsibility component.Methods: We conducted a mixed method study consisting of in-depth interviews with disenrolled members in 2016 and 2017 (n=72) and a survey of disenrolled members in 2017 (n=225).Results: Many disenrollees did not know why they were disenrolled, were unaware of the personal responsibility component or premium requirement, and were confused by the disenrollment process. Disenrollment had negative effects including stress, financial burden, and engaging in behaviors such as skipping medication and postponing medical or dental care. Furthermore, disenrollees were often unable to enroll in health insurance, and for those who did, many reported it was a difficult process.Conclusions: Disenrollment had numerous, negative impacts on members who failed to pay their premiums. There was confusion about program requirements, which might indicate challenges communicating about a complicated program. Policymakers need to consider how to design and implement personal responsibility programs to achieve their desired outcome and reduce confusion and negative consequences.

Losing Insurance and Behavioral Health Hospitalizations: Evidence from a Large-Scale Medicaid Disenrollment

We study the effects of losing insurance on behavioral health – mental health and substance use disorder (SUD) – community hospitalizations. We leverage variation in public insurance eligibility offered by a large-scale Medicaid disenrollment. Losing insurance decreased SUD-related hospitalizations but mental illness hospitalizations were unchanged. Use of Medicaid to pay for behavioral health hospitalizations declined post-disenrollment. Mental illness hospitalization financing shifted to private insurance, Medicare, and patients, while SUD treatment financing shifted entirely to patients. We investigate implications of reliance on data that is not representative at the level of the treatment variable and propose a possible solution.

The Politics of Race, Administrative Appeals, and Medicaid Disenrollment in Tennessee

In 2004, Democratic Governor Philip Bredesen of Tennessee announced a plan to reform TennCare, the state’s Medicaid program. The reform package proposed to remove 323,000 adults from the program, which represented the most drastic cuts to Medicaid since its creation in 1965. The reform measure also allowed beneficiaries disenrolled from the program to appeal the decisions to the state Department of Human Services. This study examines how race and policy backlash—that is the backlash against Medicaid expansion—influenced the appellate process for beneficiaries removed from the program in Tennessee. The main argument is that race—especially the predisposition of African Americans—influenced the outcome of the appellate proceedings. The theoretical framework advanced in this study explains how procedural deliberations (legal decisions, policy disputes, administrative hearings) exacerbate disparities and produce differential outcomes that correspond with racial and other ascriptive hierarchies. The data for this research, comprising more than 60,000 former TennCare beneficiaries, were obtained through Open Records Requests in compliance with Tennessee state law. Using logistic regressions, the findings reveal a relationship between race and appellate proceedings. African Americans were treated unfairly in the early stage of the appellate process and those from racially polarized voting areas were less likely to receive fair rulings by hearing examiners. Additional findings identified age-related disparities between younger and older appellants, as well as a regional disadvantage between rural and urban beneficiaries.