Undated file photo of Oregon Health & Science University. A recent study from the university shows that patients of color were twice as likely as white patients to lose Medicaid coverage for incomplete paperwork, missed renewal notices and other administrative issues.
Courtesy of Michael McDermott / OHSU
The federal COVID-19 emergency declaration, which expanded Medicaid coverage, officially ended last spring. Since then, state agencies that oversee Medicaid have been updating their eligibility rosters and disenrolling patients who no longer qualify. While some patients were determined ineligible, the vast majority were disenrolled for administrative reasons such as incomplete applications, incorrect paperwork and missed renewal notices.
A recent study from Oregon Health & Science University found that Black and Hispanic patients were twice as likely to lose coverage for those reasons than white patients. Jane Zhu is an associate professor of medicine at OHSU and one of the study’s authors. She joins us with more details.
Note: The following transcript was created by a computer and edited by a volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. During the height of the COVID-19 pandemic, millions of people were able to stay on their state’s Medicaid rolls because of the public health emergency. But since that emergency officially ended last year, state agencies that oversee Medicaid have been updating their eligibility rosters and dis-enrolling patients who no longer qualify. Some patients were taken off because they were ineligible, but the vast majority were disenrolled for administrative reasons. A recent study from researchers at OHSU found that Black and Hispanic enrollees were twice as likely to lose coverage for these procedural reasons than white enrollees. Jane Zhu is a primary care physician and an associate professor of medicine at OHSU. She is one of the study’s authors. She joins us once again with more details. Jane Zhu, welcome back.
Jane Zhu: Thanks so much for having me, Dave.
Miller: Medicaid enrollment increased in a lot of states, what, a decade or so ago, because of the Affordable Care Act. But that was different from the expansion during the COVID-19 pandemic?
Zhu: It was. As you mentioned, historically, Medicaid enrollees have had to reapply for Medicaid coverage every year. And that process ensured that they were meeting eligibility requirements. But because of the COVID pandemic and the public health emergency, the Centers for Medicaid and Medicare basically enacted what was called a “continuous enrollment policy,” so that paused the traditional process of redetermining eligibility. And that meant that Medicaid enrollment was automatic, enrollees had continuous coverage. As a result, enrollment grew by about 20 million people or about 30%, and corresponded to the lowest uninsured rates, historically, that we’ve seen.
This policy increased enrollment through simply making Medicaid enrollment an automatic process. But as you mentioned, April of 2023 was when this policy ended. States were given a little bit over a year to resume this redetermining process. And that period is what we now call the Medicaid unwinding period.
Miller: What do people have to do, in general, to stay enrolled in any given state’s Medicaid program?
Zhu: Well, that varies a lot state by state. But in general, there’s two different reasons for losing coverage through a re-determination process. One is you’re no longer eligible, you’re legitimately no longer eligible. For example, if you experienced an increase in income. And the second is really for procedural or administrative reasons. You didn’t fill out the paperwork, you weren’t sure, you didn’t know that your eligibility or your re-enrollment process had started, the state sent you the wrong paperwork or it sent it to the wrong address, because they had outdated contact information. So based on current estimates, about 22 million people, Medicaid enrollees, have been disenrolled. And about 70% of those have been because of procedural reasons, rather than eligibility reasons.
Miller: Why did you decide to look into race and dis-enrollment?
Zhu: What we know is that Black and Hispanic people are disproportionately enrolled in Medicaid to begin with. And the continuous enrollment policy, what it effectively did was to increase coverage across groups. But importantly, it reduced gaps in coverage, racial and ethnic gaps in coverage, that were affecting Black and Hispanic adults in particular. And so the largest Medicaid coverage gains made during that continuous enrollment period were actually among Black and Hispanic adults. That really motivated our research question, out of the concern that the disenrollment process would also disproportionately affect these groups as well.
Miller: What kind of data about race and disenrollment was there? I’m wondering how easy it was to do the analysis that you wanted to do?
Zhu: I’ll just say, states are not required to report race and ethnicity data on disenrollments that they’ve experienced thus far. About nine or 10 states, just a handful really, report this data. So what we did to get at this question was, we used publicly available data from a survey called the “Household Pulse Survey” that is administered by the U.S. Census Bureau, and it’s a nationally representative survey. But what this relies on is self-reported race ethnicity data, which is a huge advantage for our purposes. And then the second advantage I would say is that the data is collected very frequently and continuously through the COVID pandemic, so that allows us to track these trends over time.
Miller: Your big finding was that Black and Hispanic enrollees were twice as likely as white enrollees to be disenrolled for these procedural reasons. Does the data explain why?
Zhu: It doesn’t. I think that’s the main issue. A lot of the questions about why this is happening is more conjecture. Like you said, what we found was that Black and Hispanic individuals were disproportionately represented among people who said they lost coverage because of procedural reasons. Certainly, there may be limitations to the study. For example, it’s possible that, given the sheer complexity of Medicaid eligibility, that respondents could have attributed their loss erroneously to administrative reasons.
But that being said, we did detect a very significant difference in Medicaid procedural disenrollment among Black and Hispanic individuals. And there’s a couple of potential reasons. I’ll give you an example. Obviously, we’re talking about structural reasons, but in general, Black and Hispanic individuals are more likely to be residing in non-expansion states. And some of these states that are non-expansion states may also have less resources, labor committed to the enrollment processes.
Miller: When you say non-expansion states, can you explain what that means?
Zhu: I’m talking specifically about the ACA Medicaid expansion versus non-expansion programs, and a lot of states initiated expansion policies. But there are a number of states that chose not to expand Medicaid as a result of the ACA.
Miller: States that made the policy choice to put fewer resources towards their Medicaid programs, how might that lead to racial disparities in procedural disenrollment? What’s the mechanism that you’re positing?
Zhu: What we’ve seen is that this process has really varied widely from state to state. And I’ll take this explanation all the way through what we’ve seen in some states. Texas, for example, has experienced very high disenrollment rates. Others like Maine and even Oregon have reported very low disenrollment rates. Some of this state variation could be due to differences in renewal policies and timing, but also it’s a matter of system capacity.
What we see in states that have less of this disenrollment due to procedural reasons is that they are investing in community outreach. They are investing in educational resources to help Medicaid enrollees navigate the renewal process. Black and Hispanic communities as well as disabled communities, other low income communities, are most at risk for not having those resources for navigation. They may need additional engagement around the renewal process. The states may need to be better at collecting and tracking contact information if people are moving around a lot.
So it directly relates in a way that the resources the state is able to devote to these engagement and outreach processes to streamline the complexity of the paperwork needed to renew your Medicaid enrollment, that directly links to the outcomes that we’re seeing.
Miller: What’s the purpose of some of this paperwork to begin with? I’m wondering, for example, if a big part of this is income verification, do these agencies not have access to that already? Do they not have access to tax filing information? Do they need to have a separate system to verify income?
Zhu: This is hitting the nail on the head, Dave. So, again, in some states, this process is automated, which is a protective factor against these erroneous disenrollments. But in some states, this is a manual process, where Medicaid enrollees are required to fill out paperwork and to submit this information that might be really hard for some people to get. So when we talk about state mitigation strategies, things that could help reduce or stem these coverage losses, one of the things that people talk about often is to adopt the automated re-enrollment processes, to make it so that enrollees only have to provide minimal paperwork or really none at all. Because some of this data is actually easily available and can be found in other places.
Miller: I guess another way to look at this is, I’m wondering if you see these procedural disenrollments as a feature of some state systems, as opposed to a bug?
Zhu: This is getting into more of a normative and political question, I think. Yes, I think that to a very general extent, some states may see the enrollment and renewal processes as a way to ensure that the people who are on Medicaid are the ones that are truly deserving, and to reduce the chance that there are people who are taking advantage of the system.
And in other states, that might be a very different political calculation, a very different policy or implementation strategy, and that may play out in what we see in terms of states that have very, very high disenrollment. Texas, for example, 60% or higher of the Medicaid rolls were actually disenrolled at some point during this unwinding period, versus the states that are lower in these processes. I think, unfortunately, the politics and the philosophy behind how states are thinking about their Medicaid programs, probably does play a role.
Miller: Do you see any movement at the federal level or at individual state levels to change these policies in meaningful ways?
Zhu: There’s been a lot of discussion, I think, at the federal level. There’s been a lot of guidance for states to consider mitigating some of these coverage losses in a variety of ways. We talked already about the community outreach and educational resources, but some states have been encouraged to get their plans and providers like myself to be also active with engagement and outreach around the renewal process.
And then, states are trying to do a lot of different things, like allowing renewal requests to be processed through not just mail or phone but also online. And like I said, the main issue here is trying to streamline the demands and the paperwork that are required to stay enrolled in Medicaid, particularly if you’re still eligible. So a number of states have adopted these automated re-enrollment processes that we think is a very positive development. Really trying to reduce the manual driving and room for error that can occur when you’re trying to get everybody to submit their information separately through these complex processes.
Miller: Jane Zhu, thanks very much.
Zhu: Thanks so much for having me, Dave.
Miller: Jane Zhu is a primary care physician and an associate professor of medicine at OHSU.
Contact “Think Out Loud®”
If you’d like to comment on any of the topics in this show or suggest a topic of your own, please get in touch with us on Facebook, send an email to thinkoutloud@opb.org, or you can leave a voicemail for us at 503-293-1983. The call-in phone number during the noon hour is 888-665-5865.