Research Finds Significant Racial Disparities in Medicaid Re-enrollment

Black and Hispanic Americans were twice as likely as white Americans to lose Medicaid last year because of an inability to complete renewal forms during a vast trimming of the program’s rolls, according to a study published on Monday in the journal JAMA Internal Medicine.

The findings from researchers at the Oregon Health & Science University, Harvard Medical School and Northwestern University are some of the first comprehensive data on race gathered after a pandemic-era policy that allowed Medicaid recipients to keep their coverage without regular eligibility checks ended last year.

More than 22 million low-income people have lost health care coverage at some point since April 2023, when the policy allowing continuous enrollment lapsed. The process of ending that policy — what federal and state officials have called “unwinding” — was one of the most drastic ruptures in the health safety net in a generation.

“Medicaid eligibility is complex, and then applying and keeping Medicaid coverage is a huge logistical barrier,” said Dr. Jane M. Zhu, an associate professor of medicine at the Oregon Health & Science University and one of the study’s authors. “What this analysis is showing is that these barriers have downstream spillover effects on particular communities.”

Researchers have found that increases in health insurance coverage across racial and ethnic groups from 2019 to 2022 were largely driven by Medicaid.

A provision in a coronavirus relief package passed by Congress in 2020 required states to keep recipients of the joint federal-state health insurance program for the poor continuously enrolled in exchange for additional federal funding.

By early 2023, more than 90 million people were enrolled in Medicaid and the Children’s Health Insurance Program, or more than one in four Americans. That was up from about 70 million people at the start of the coronavirus pandemic. About half of Medicaid enrollees are Black or Hispanic, and around 40 percent are white.

As of May, Medicaid enrollment had declined by more than 13 million, including more than five million children, according to the Georgetown University Center for Children and Families.

Many of those who lost coverage had incomes that were too high to qualify for Medicaid or had aged out of the program. But about 70 percent of those who lost coverage might have still been eligible and fell out of Medicaid because of bureaucratic reasons, such as failing to return paperwork on time, according to KFF, a nonprofit health policy research group.

The study published on Monday, which used Census Bureau survey data on health insurance enrollment from late March 2023 to October 2023, focused on the group of Americans who lost coverage for technical reasons.

There is otherwise little data from the unwinding to help researchers and federal officials understand who has been affected most from the shrinking of the Medicaid rolls.

The Centers for Medicare and Medicaid Services did not require states to report enrollment decisions during the unwinding by race or ethnicity. Only about 10 states have shared that data with the Biden administration.

“This data is vitally important and is information that we simply don’t have,” said Jennifer Tolbert, a Medicaid and state health policy expert at KFF.

The study did not determine that Black and Hispanic people were more likely than white people to lose Medicaid, only that they represented a disproportionate number of those who could not complete the renewal process.

Dr. Zhu acknowledged other limitations to the study. Because the data was self-reported, she said, some Medicaid recipients might have actually lost coverage because they were no longer eligible and believed they had been dropped from the program for bureaucratic reasons.

Health policy experts said the study exposed how diffuse and varied Medicaid administration could be, with sometimes significant demands on enrollees who might not have internet access or the ability to renew their coverage in person with state officials.

Ms. Tolbert pointed to findings from a recent KFF survey that showed Black and Hispanic adults were more likely than white adults to be asked to prove their residency as part of renewing their Medicaid coverage.

States have also used different technology and procedures to vet Medicaid eligibility, some of which contained glitches that led to program recipients being unfairly disenrolled.

The differences in state unwinding strategies have had “big implications on the ability of people to enroll or renew their coverage,” Ms. Tolbert said.

Dr. Zhu said fixes for the study’s findings should be “low-hanging fruit.”

“Do we have the right contact information? Are we sending enrollment and eligibility paperwork to the right people at the right time? Are we considering all different forms of automatically re-enrolling individuals?” she said. “These are all things that are systems issues, systems barriers that should be easy to address, and by addressing them can limit disruptions.”