Confusion About Medicaid Skewing Coverage Estimates, Study Finds

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Dive Brief:

• The number of people enrolled in Medicaid soared over the pandemic due to federal restrictions on states removing members from the safety-net insurance program. However, many of those people may not have known their coverage had continued, a new study suggests.
• Medicaid coverage as a share of the overall population jumped by 5.2 percentage points between 2019 and 2022, according to CMS statistics. However, the change in survey-reported Medicaid coverage was much smaller — an increase of 1.3 percentage points, according to the study published Friday in JAMA.
• The findings suggest the government needs to do a better job of communicating with Medicaid members about changes to their coverage — a particularly important goal as states recheck Medicaid eligibility, researchers said.

Dive Insight:

Medicaid enrollment skyrocketed to cover one in four Americans during the COVID-19 pandemic, as states agreed not to boot individuals off Medicaid in return for more generous federal funding.

However, that agreement ended in April 2023, allowing states to once again assess the eligibility of their Medicaid beneficiaries. At least 19.6 million people have lost coverage to date as a result, according to a tracker by health policy research nonprofit KFF. States are expected to finish unwinding by the middle of this year.

Prior research suggests Medicaid enrollment growth exceeded survey-reported rates of Medicaid coverage in 2021, raising questions about how much beneficiaries understood what was going on with their coverage during the pandemic.

It’s a discrepancy researchers sought to square in the new study, which analyzes differences between self-reported survey data of U.S. residents compared to administrative data from the CMS.

The study found the uninsured rate dropped “considerably” from 2019 to 2022, but that drop was one-fourth as large as the growth in Medicaid enrollment. Meanwhile, survey-based Medicaid growth was smaller than growth as tallied by the federal government.

The gap between administrative and self-reported Medicaid coverage increased from 1.7% of the population in 2019 to 5.6% in 2022. In 2019, 34 states and Washington, D.C. had a survey Medicaid undercount. By 2022, all 50 states and Washington, D.C. had an undercount, according to the study.

This could be due to confusion among beneficiaries about how to report their coverage, but more likely many people who stayed on Medicaid during the COVID continuous enrollment might not have realized that, researchers said. Typically, Medicaid eligibility lasts a year before it needs to be renewed.

The growing  disconnect suggests a “missed opportunity to promote continuity of care during the pandemic, as some beneficiaries appeared not to understand that their Medicaid coverage had remained in place for more than 2 years without requiring an eligibility redetermination,” researchers said.

“Given research evidence that changes in coverage — so-called ‘churning’ — has numerous negative financial and health-related effects, future policy efforts to promote continuous coverage need to be clearly communicated to patients,” they continued.

Other research has found Medicaid members were confused about continuous enrollment and have remained uncertain about their coverage through redeterminations. A majority of Americans that have lost coverage have lost it not due to actual ineligibility but because of procedural reasons, like missing or unclear paperwork.

Along with cracking down on such procedural terminations, the Biden administration has also taken some steps to make it easier to access Medicaid coverage.

Starting this year, all states are required to provide 12 months of continuous coverage for children in safety-net insurance programs. And last month, regulators finalized a rule aimed at simplifying Medicaid enrollment and renewal.