Medicaid Coverage Losses During Unwinding: Differences by Parental Nativity and State Policy

• In Event: Administrative Burdens in Healthcare: Evidence for Multiple Disciplines

Abstract

The Consolidated Appropriations Act of 2023 ended the pandemic-era continuous Medicaid enrollment provision, effective March 31, 2023, requiring states to resume eligibility redeterminations during a 14-month unwinding period. Existing research documents substantial declines in Medicaid coverage among adults during this period, but limited research has examined heterogeneity in changes in children’s Medicaid coverage, particularly by parental nativity. Because the barriers to and facilitators of eligibility redeterminations faced by adults could shape their children’s likelihood of successful Medicaid renewal, and immigrant parents may face additional or unique barriers, this study examines how pre-existing state Medicaid policy environments, including eligibility and coverage policies and administrative practices, are associated with changes in Medicaid/CHIP and overall health insurance coverage among children, particularly children of immigrants.

This study draws on data from the 2022 and 2024 one-year American Community Survey (ACS) to examine changes in Medicaid/CHIP coverage and any health insurance coverage among children ages 0-18 in health insurance units (HIUs) with incomes below 300% of the federal poverty guidelines (FPG), comparing the pre-unwinding (2022) and later-unwinding (2024) periods. Triple-difference regression models are estimated to examine (1) coverage changes in states with and without each policy, separately for children of foreign-born parents and those of U.S.-born parents, and (2) whether the differences in coverage changes between states with and without each policy vary by parental nativity.

Policy measures include two groups of policies and practices: (1) pre-existing eligibility and coverage policies, including 12-month continuous eligibility for children, ACA Medicaid expansion, Medicaid/CHIP income limits at or above 300% FPG, additional coverage of immigrant children with state-only funds, and separate versus combined Medicaid/CHIP program structures; and (2) administrative renewal and outreach policies and practices: including ex parte renewals, coordination with managed care organizations (MCOs) to update contact information, follow-up renewal notices, text/email methods of contact, and translated online application systems.

Preliminary findings indicate that pre-existing state Medicaid coverage policies are associated with smaller Medicaid/CHIP coverage declines among children with foreign-born parents. Among children of immigrants, adjusted coverage declined by 1.65 percentage points in states with 12-month continuous eligibility, compared with 7.26 percentage points in states without the policy (difference: 5.61 percentage points, p < 0.01). The corresponding difference among children with U.S.-born parents was 1.94 percentage points, yielding a significant triple-difference estimate of 3.67 percentage points (p < 0.01). ACA Medicaid expansion and state-funded coverage for immigrant children are also associated with substantially smaller coverage declines among children with foreign-born parents, with differences of 6.07 and 6.20 percentage points, respectively (both p < 0.01). In contrast, administrative practices adopted for unwinding showed less consistent associations with coverage changes. We discuss the study’s limitations and implications for policies aimed at improving coverage continuity among children of immigrants.

Authors

• Yiyu Chen, Independent
  Presenting Author

• Christopher Wodicka, University of Pennsylvania
  Non-Presenting Co-Author