The great “unwinding” of Medicaid

The COVID-19 public health emergency led to federal legislation that changed the landscape of Medicaid coverage for millions of low-income people in the United States. The enormous temporary expansion of Medicaid enrollment highlighted Medicaid’s role as a safety net program and the need for researchers and policymakers to further understand the implications of such programs during times of economic hardship.

New Texas A&M University research explores various Medicaid policy changes and what they mean for future policy research and practice. Benjamin Ukert, PhD, assistant professor at the Texas A&M University School of Public Health, and Laura Dague, PhD, associate professor at The Bush School of Government & Public Service, reviewed literature on Medicaid policies related to enrollment and disenrollment, described effects of policy changes during the COVID-19 public health emergency, and outlined key questions for researchers and policymakers to consider in the future.

Ukert and Dague first reviewed Medicaid policies before 2020. Each state designs and implements Medicaid plans following federal guidelines. Medicaid eligibility is based on household income and factors like age, disability and pregnancy, and states have leeway in setting eligibility policies. Policies on how to apply for Medicaid also vary from state to state, with some states making it easier to apply than others.

In 2020, the federal government implemented policies in response to the COVID-19 pandemic that increased funding to state Medicaid programs and temporarily eliminated eligibility redeterminations. This meant beneficiaries would not lose coverage despite changes to eligibility while these policies were in effect. Job losses in the early stage of the pandemic, and subsequent losses of employer-sponsored insurance, contributed to an increase in Medicaid enrollment in 2020. These factors led to a greater increase in total Medicaid enrollment from 2020 to 2023 than was seen between 2013 and 2017 after the implementation of the Affordable Care Act (ACA).

The measures put in place in 2020 were meant to be temporary, and starting April 1, 2023, states were once again able to begin reviewing beneficiaries for eligibility and disenroll beneficiaries. Most states have plans for a staggered redetermination of eligibility of beneficiaries over a period of 14 months. This so-called unwinding could lead to some people losing health insurance coverage; however, the degree of this loss is an open question for researchers and policymakers.

“A state’s ability to process a large number of renewals will likely influence the length of the process,” Ukert said. “However, generous premium subsidies in the ACA marketplace means that a smaller proportion of people could end up without insurance after Medicaid disenrollment.”

Because the future of Medicaid enrollment following the COVID-19 pandemic is unclear, Ukert and Dague identified a few key questions to guide additional research on the topic. These include questions about the impacts of continuous coverage on health care coverage and costs, how best to target efforts to redetermine Medicaid eligibility, whether increased Medicaid funding served as an economic stimulus and how researchers should consider the 2020-2023 period when conducting long-term studies on Medicaid.

Changes to Medicaid policies that started in 2020 and are currently unwinding have had an unprecedented effect on health care in the United States. And there will likely be additional changes seen in the coming months as states return to pre-pandemic policies.

“Having a better understanding of how state and federal regulations have changed during COVID-19 and afterwards and knowing what to investigate will likely help researchers and policymakers to develop future research projects and develop policy recommendations,” Ukert said.