Racial disparities persist after the repeal of the Medicaid Continuous Coverage Requirement
Systemic disparities rooted in historical and ongoing racism are responsible for racial disparities. A recent study revealed that during the COVID-19 PHE, racial minority groups experienced higher rates of Medicaid de-enrollment than dominant ethnicities. Black and Hispanic people were disproportionately affected. Loss of coverage for health care exacerbates racial differences in health care utilization and access, which result in disproportionate outcomes. The Centers for Medicare & Medicaid Services (CMS), which administers the Medicaid program, offered state Medicaid agencies a variety legal tools to help them deal with the challenges of processing the high volume of renewals that occurred during the unwinding. CMS offered several flexibility tools to curb disenrollments for administrative or paperwork reasons (often called “procedural” disenrollments). States were free to use these tools, and the implementation of federal flexibilities varied from state to state. CMS unwinding data suggests
that states that adopted flexibility saw fewer Medicaid terminations. States that reduced procedural disenrollments reduced the disproportionate impact on racial minority groups of Medicaid terminations during the unwinding. Nearly 70% of Medicaid Terminations During the Unwinding Were for Paperwork ReasonsProcedural disenrollments raise concerns for both Medicaid beneficiaries and health care advocates. During the unwinding process, state Medicaid agencies sent renewal paperwork to many enrollees. There were many long-standing issues with the mailing and completion of renewal forms. These included beneficiaries not receiving renewals forms, delays in sending out renewals forms, complex and contradictory information on renewal forms which made them difficult to understand, as well as other barriers to beneficiaries submitting their renewal forms. As a result, millions of Medicaid enrollees lost their eligibility for the program despite still being eligible. Recent data
show that since the beginning of unwinding, approximately 24 million Medicaid enrollees have had their coverage discontinued. Just under 70% of these disenrollments are for procedural reasons. It is not known what percentage of disenrolled individuals would have been able to retain their Medicaid coverage, but the statistics show that millions of beneficiaries could have been terminated in an inappropriate manner. A recent
KFF study
revealed that 47% of people who were disenrolled re-enrolled. Procedural Disenrollments disproportionately impacted racial minority groupsA majority of Medicaid enrollees is racial minority and a majority of those disenrolled during the unwinding of Medicaid were racial minority. Insufficient data exist to determine if disenrollments are racially disproportionate in the Medicaid population. According to a recent study
, more people who said they couldn’t complete the renewal process were Black or Hispanic than the total Medicaid population. Nationally, Black individuals made up 16% Medicaid population but accounted for 22% who reported not being able to complete their renewal paperwork. The same figures were observed among enrollees who identified themselves as Hispanic. They make up 23% percent of the Medicaid population, but 34% of them could not complete their renewal paperwork. Black and Hispanic people were twice as likely to report losing Medicaid due to inability to renew paperwork as white people. This data confirms that different populations have different interactions with state Medicaid agencies, and the Medicaid renewal processes. Research shows that adults with limited English skills (LEP) have difficulty obtaining and maintaining Medicaid coverage, even when they qualify. This is because of language barriers. The Medicaid population is disproportionately made up of individuals with LEP, which could explain some of the disparities in the disenrollments that occur during the unwinding. And relatedly, because BIPOC individuals are significantly more likely to have LEP than white individuals, language barriers also exacerbate racial and ethnic health disparities.
Data limitations coupled with differences in demographics and Medicaid unwinding processes across states could also partially explain the disparities in Medicaid disenrollments across the country. To improve renewal processes for Medicaid, equity initiatives will be needed, especially for populations that are more likely to have difficulty retaining coverage. NHeLP advocates for race-conscious policies and culturally-informed support to address the racial obstacles observed during the unwinding. Racial disparities in Medicaid disenrollments are likely to persist if states fail to safeguard against procedural terminationsIn an effort to curb racial disparities in Medicaid disenrollments, states should consider and enact policies to reduce procedural disenrollments. During the unwinding, CMS provided options for states to streamline and simplify renewals, and almost all states took advantage of these federal waivers but states implemented these waivers in varying degrees. Many of these flexibilities, if implemented more widely, could help reduce racial disparities during Medicaid renewals.
ex part renewals, for example, allow beneficiaries to renew eligibility without having any direct contact with state Medicaid agencies. The renewals Ex part
avoid the language barrier issues that can arise when communicating complex information with diverse individuals and those with LEP. The unwinding the Medicaid continuous coverage requirements highlighted the disproportionate harm minorities experience when renewing Medicaid, perpetuating systemic racist and racial inequality in the U.S. healthcare system. The ongoing race-related problems observed during unwinding do not have to be ignored. There are a number of legal tools available to reduce disparate outcomes and ease administrative burdens on Medicaid applicants and enrolled individuals. States can, for example, improve LEP communication at call centers, communicate more frequently via text message, and make online service more accessible. Research shows that these efforts improved Medicaid access and utilization in the previous and are worth implementing for the future. Medicaid is a vital part of the health care system. It is important that states implement culturally and equity-informed responses to reduce administrative costs for all those who qualify for Medicaid coverage in the United States.
