Poster #111 - “This Stress Can Actually Wear On My Body”: Downstream Health Impacts of Medicaid Administrative Burden

• In Event: Saturday Poster Luncheon

Abstract

Scholars identify administrative burden – learning, compliance, and psychological costs of negative bureaucratic encounters – as a barrier to accessing health-promoting social welfare programs, including Medicaid. Amid ongoing federal and state-level Medicaid policy changes, less is known about the downstream health impacts of these encounters for currently enrolled Medicaid beneficiaries. 

We examined how currently enrolled Medicaid beneficiaries experience learning, compliance, and psychological costs of both current program administration and proposed design changes and understand the health impacts they attribute to it. We conducted semi-structured interviews with 43 adult North Carolina Medicaid beneficiaries from August to October 2025, purposively sampled to capture variation in race/ethnicity, rural/urban residence, sex, Medicaid plan type, and enrollment duration. Interviews were part of a broader multi-year evaluation of North Carolina Medicaid's transition from fee-for-service to managed care under the Medicaid 1115 Demonstration Waiver. Data were coded using an a priori codebook informed by policy context and administrative burden theory, with emergent codes added inductively. We conducted thematic analysis of perceived burdens and health impacts. 

Most participants reported at least one negative bureaucratic encounter while attempting to use Medicaid services. Three interrelated themes emerged from these findings. 

First, participants directly attribute negative health impacts to administrative burden. Psychological costs included stress and emotional distress following negative encounters with program administrators or third-party agents. Learning and compliance costs were associated with health-related harms, such as missed medications, missed appointments, delayed care, and coverage denials, often driven by opaque appeals processes or difficulty locating participating providers. This provides some of the first evidence of beneficiaries’ perceptions of downstream health impacts from learning and compliance costs. 

Second, anticipation of future administrative burden creates present harms for beneficiaries. Participants described uncertainty surrounding anticipated policy changes, including new federal work requirements and more frequent eligibility checks. Participants shared psychological costs, such as emotional distress, hours spent trying to determine future eligibility, or delaying life events like having a child due to a lack of clarity about future compliance costs.  

Finally, repeated administrative burden exposures contributed to broader disengagement from Medicaid. This was especially common among participants facing high unmet health-related social needs, such as housing instability, food insecurity, and transportation barriers. Disengagement was linked to unmanaged physical and behavioral health conditions, suggesting that individual-level characteristics moderate the ability to “pay the costs” of administrative burden.  

This study extends administrative burden research by examining experiences of currently enrolled Medicaid beneficiaries and identifying pathways through which learning, compliance, and psychological costs may undermine health. As states implement anticipated changes to Medicaid program designs and eligibility requirements, identifying opportunities for program administrators to reduce administrative burden is essential to ensure Medicaid programs meet objectives for beneficiaries.

Author

• Alexandra Robinson, University of North Carolina at Chapel Hill
  Presenting Author