Systemic inequalities rooted in historic and ongoing racism lead to racial disparities in health outcomes. A recent study found that during the recent unwinding of the COVID-19 public health emergency (PHE), racial minorities experienced higher rates of Medicaid disenrollments compared to dominant ethnicities. In particular, Black and Hispanic individuals were disproportionately negatively impacted. Loss of health care coverage exacerbates racial disparities in health care access and utilization, which ultimately result in disproportionate health outcomes.
The Centers for Medicare and Medicaid Services (CMS) offered state Medicaid agencies that administer the Medicaid program a variety of legal tools to combat the challenges of processing a high volume of renewals during the unwinding. Specifically, CMS offered several flexibilities to curb disenrollments due to administrative or paperwork reasons, often called “procedural disenrollments.” Whether states took advantage of the tools was entirely within their discretion, and implementation of federal flexibilities varied by state. CMS’ unwinding data suggests that states that adopted flexibilities saw fewer Medicaid terminations, especially procedural disenrollments. Thus, states who reduced procedural disenrollments likely reduced the disproportionate impact of Medicaid terminations on racial minorities during the unwinding.
Nearly 70% of Medicaid Terminations During the Unwinding Were for Paperwork Reasons
Procedural disenrollments raise concerns for both Medicaid beneficiaries and health care advocates. During the unwinding, state Medicaid agencies mailed many enrollees renewal paperwork. Many long standing issues arose with mailing and completing renewal forms, including beneficiaries not receiving renewal forms, delays in mailing out renewal forms, complex and conflicting information in renewal forms that made them hard to understand, and other barriers to beneficiaries being able to submit their renewal forms.
As a result of these barriers to completing Medicaid renewals, millions of enrollees were discontinued from Medicaid while still remaining eligible for the program. Recent data shows that approximately 24 million Medicaid enrollees had their coverage discontinued since the start of unwinding, and just under 70% of those disenrollments were for procedural reasons. It is unclear what proportion of disenrolled individuals could have retained their Medicaid coverage but the statistics do show that potentially millions of beneficiaries were inappropriately terminated and that those terminations disproportionately affected minority populations. In fact, a recent KFF survey showed that 47% of those who were disenrolled later re-enrolled in the program.
Procedural disenrollments disproportionately affected racial minorities
A majority of Medicaid enrollees are racial minorities and a majority of those disenrolled from Medicaid during the unwinding were racial minorities. There is insufficient data to analyze whether disenrollments were racially disproportionate within the Medicaid population itself. However, according to a recent study, a higher percentage of individuals who reported that they were unable to complete the renewal process identified as Black or Hispanic compared to the overall Medicaid population. Nationwide, individuals who identified as Black made up 16% of the Medicaid population yet accounted for 22% of those who reported being unable to complete their renewal paperwork. Similar figures were observed for enrollees who identified as Hispanic, who make up 23% of the Medicaid population but accounted for 34% of those who could not complete renewal paperwork. Black and Hispanic individuals were twice as likely as white individuals to report losing Medicaid coverage due to the inability to complete the renewal process.
This data confirmed that different populations interact differently with state Medicaid agencies and the Medicaid renewal process. For example, research shows that adults with limited English proficiency (LEP) experience challenges securing and retaining Medicaid coverage even when they are eligible because language barriers make it burdensome to navigate Medicaid’s administrative system. Individuals with LEP make up a disproportionate share of the Medicaid population which could account for some of the disparities observed in procedural disenrollments 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. Nonetheless, equity initiatives are needed to improve renewal processes, particularly for populations more likely to experience challenges retaining Medicaid coverage. NHeLP continues to advocate for culturally-informed supports and race-conscious policy measures to address the racial barriers observed during the unwinding.
Racial disparities in Medicaid disenrollments are likely to persist if states fail to safeguard against procedural terminations
In 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. If implemented more broadly, many of these flexibilities could help reduce the racial disparities observed during Medicaid renewals. For example, ex parte renewals allow beneficiaries to renew their eligibility without any direct contact with the state Medicaid agency. Ex parte renewals avoid language barrier issues and other complications that arise when communicating complex information to diverse individuals and individuals with LEP.
The unwinding of the Medicaid continuous coverage requirement highlighted the disproportionate harm that minority communities experience in Medicaid renewals, perpetuating systemic racism and racial inequity in the U.S. health care system. However, the ongoing race-related issues observed during unwinding are not helpless, as a variety of legal tools exists to curb disparate outcomes in renewals and ease the administrative burden on Medicaid applicants and enrollees. For example, states can improve LEP communications at call centers, communicate via text message more frequently, and make online services more accessible. Research shows that these efforts have improved Medicaid accessibility and utilization in the past and are worth implementing in the future. Given Medicaid’s importance in the health care system, it is imperative that states pursue culturally- and equity- informed responses to reduce administrative burdens for all those who are entitled to Medicaid coverage across the country.
