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Milken researchers find drops in health care coverage after Medicaid disenrollment

Arwen Clemans | Staff Photographer
The George Washington University Hospital entrance on 23rd Street.

Researchers in the Milken Institute School of Public Health found significant drops in health care coverage at health centers serving low-income communities after last year’s mass Medicaid disenrollment in a study published earlier this month.

Researchers sent surveys to more than 1,000 community health centers, which provide affordable health care to low-income areas, and found that 95 percent of health centers saw patients disenroll from Medicaid after the COVID-19 pandemic-era continuous enrollment provision — which paused pandemic-era eligibility checks — ended in March 2023. Peter Shin, an associate professor of public health and the study’s lead researcher, said the disenrollment causes vulnerable populations like low-income patients and communities of color to lose health care coverage and delay medical treatment because they fear they won’t be able to pay.

Medicaid provides health care coverage to low-income and disabled people, which helps community health centers receive compensation for treatment because the centers provide care at a reduced cost for uninsured patients. When patients do not have insurance that can pay the centers back fully, the centers lose revenue.

During the pandemic, Congress paused Medicaid “churn,” or eligibility inspections based on income changes that may cause patients to lose coverage, requiring Medicaid programs to keep patients enrolled throughout the pandemic. After the pause expired, and as a result, state Medicaid agencies informed people that they no longer had coverage, who are struggling to complete the paperwork.

“The biggest finding was that every health center, to no surprise, reported that they saw unwinding impacts on their patients,” Shin said. “The biggest one was that the estimate of about one in four patients losing coverage.”

The Geiger Gibson Program in Community Health, a program in Milken’s Department of Health Policy and Management, partnered with the National Association of Community Health Centers to survey the CEOs of community health centers about the number of patients that had disenrolled from Medicaid and their demographics.

Shin said the study found that among the 95 percent of community health centers that reported disenrollment, nearly one in four patients were disenrolled. He said researchers thought these centers would be most impacted by the unwinding because many of their patients rely on Medicaid and the centers primarily serve low-income communities and communities of color.

“We want to be able to capture what the impact would be for this group of highly vulnerable or high risk or populations at high risk of poor health issues,” Shin said.

The study found that of those disenrolled, 74 percent of patients failed to re-enroll. Shin said people had difficulty re-enrolling and proving their eligibility due to the amount of paperwork.

In order to re-enroll in Medicaid, a patient must update their contact information with their state Medicaid office, check their mail for information on their eligibility and if they are eligible, fill out a renewal form that they will receive via mail. The process and eligibility requirements vary by state.

“Half or more than half reported that they saw major disruption in patient care, some patients simply couldn’t come back or continue with their treatment,” Shin said. “A lot of the things that we were kind of expecting, we’re just kind of blown away by how severe it was, in terms of the reporting.”

The Affordable Care Act in 2010 required states to expand Medicaid eligibility to allow more people to get coverage by adjusting the income limit on eligibility, but the Supreme Court in 2012 ruled that states cannot be forced to abide by this. As a result, 40 states and D.C. have expanded Medicaid while 10 have not.

Shin said the study found that more people had disenrolled in Medicaid expansion states than in the states where Medicaid was not expanded. The study found that in nonexpansion states, 40 percent of those disenrolled were children.

“They’re delaying their care,” Shin said. “They’re postponing their treatment. They’re not coming in for routine visits. So it’s obviously gonna have severe impacts for their health down the road.”

Rebecca Morris, a public health graduate student and research associate on the study, said Medicaid disenrollment threatens community health center operations because of the loss of revenue that comes with the rise in uninsured patients, since the centers treat patients regardless of their ability to pay.

Morris said the disproportionate loss of coverage among vulnerable populations like children, the disabled and the elderly means it is likely especially hard for them to navigate the re-enrollment process and complete the necessary paperwork. She said there needs to be increased communication between community health centers and Medicaid agencies to help patients re-enroll.

“We really want to make sure that there’s a lot of integration where health centers and local Medicaid agencies are talking,” Morris said. “That we are learning more about the issues that patients are having with trying to re-enroll in Medicaid and the confusion and trying to kind of fix some of those gaps and hopefully in the future from this, we’ll be able to take away best practices.”

Experts in healthcare said states need to simplify the process of re-enrollment and expand outreach to people who have lost coverage but are still eligible for Medicaid by providing information on re-enrollment on social media.

Diane Rowland, the executive vice president emerita of the Kaiser Family Foundation, a health policy research nonprofit, said states should streamline the process of re-enrollment by designating place for people to re-enroll or by having enrollment days held at health centers.

“Can you make the redeterminations done at a community health center?” Rowland said. “Can you have outreach workers that help do it? Some states have been very effective in trying to go out and really have enrollment days and a lot of outreach and other states just let people fall through the cracks.”

Rachel Swindle, a research fellow at the Center on Health Insurance Reforms at Georgetown University, said states must realize that young people, who often do not check their email or answer their phone, would benefit more from social media outreach to learn how to re-enroll.

“​​Trying to meet people where they’re at and, for example, sending text messages,” Swindle said. “Everyone in our generation, Gen Z, millennials, we don’t answer the phone. We don’t necessarily check our mail that frequently, so sending text messages or putting ads up on Instagram or TikTok.”

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