Q&A: End of public health emergency may widen racial disparities in Medicaid

Key takeaways:

• Older Medicare beneficiaries with low incomes often have difficulty paying for care.
• As the public health emergency ends, the loss of supplemental Medicaid insurance may have harmful and inequitable impacts.

Losing eligibility for Medicaid supplemental insurance was linked to worse health care outcomes for people from underrepresented racial and ethnic populations, according to researchers.

Eric T. Roberts, PhD, an assistant professor of health policy and management at the University of Pittsburgh School of Public Health, and colleagues conducted a cross-sectional study to assess the health consequences of surpassing Medicaid’s income threshold, leading to a sudden loss of Medicaid eligibility.

The researchers evaluated data from 8,144 Medicare beneficiaries in the 2008 to 2018 biennial waves of the Health and Retirement Study that were linked to 2007 to 2018 Medicare administrative data. They also compared discontinuities in outcomes among Black (14.8%), Hispanic (13.6%) and white (71.6%) beneficiaries to identify disparities connected to the loss of Medicaid eligibility.

Roberts and colleagues found that surpassing the Medicaid eligibility income threshold was linked to a 31 percentage point (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among white beneficiaries and a 43.8 percentage point (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries.

Additionally, losing eligibility for Medicaid supplemental insurance above the federal poverty level was linked to higher racial and ethnic disparities in health care. Among Black and Hispanic beneficiaries, the researchers reported that exceeding the income threshold increased the probability of experiencing cost-related barriers to care by 5.7 percentage points (95% CI, 2.0-9.4). It was also associated with lower outpatient use (6.3 services per person-year; 95% CI, 10.4 to 2.2) and fewer medication fills (6.9 fills per person-year; 95% CI, 11.4 to 2.5).

Roberts told Healio that the findings have implications for the Biden administration’s plan to end the COVID-19 emergency declarations in May.

During the public health emergency, continuous Medicaid coverage was available under the Families First Coronavirus Response Act, according to an HHS press release. As the public health emergency ends, so will continuous Medicaid coverage provisions, and states will need to restart Medicaid and Children’s Health Insurance Program (CHIP) eligibility reviews. HHS called the expiration of the requirement “the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act.”

Healio spoke with Roberts to learn more about the importance of the findings, how the public health emergency ending might affect current health disparities and more.

Healio: What are the clinical implications of your findings? What is the take-home message for PCPs?

Roberts: A major takeaway of our study is that low-income older adults often have difficulty paying for care, even when they are covered by Medicare. The Medicare program has high out-of-pocket costs, including deductibles, co-pays and co-insurance. National studies have found that about 15% of Medicare beneficiaries report difficulty paying for care. This number increases to 30% among Medicare beneficiaries with low incomes.

Nearly one-half of Medicare beneficiaries have incomes below 200% of the federal poverty level (below $29,000 for a single person in 2023), yet only those with incomes below 100% of the federal poverty level (below $14,500) qualify for Medicaid supplemental insurance, which pays for these out-of-pocket costs. The abrupt cutoff in Medicaid eligibility at the federal poverty level leads to a “cliff” in Medicaid insurance for “near poor” older adults on Medicare. Because of this cliff, older adults can face substantially higher deductibles and co-pays despite often having limited means to pay for these costs.

Our study shows that this cliff in Medicaid assistance has a greater effect on Black and Hispanic older adults’ ability to pay for care, compared to its effect for white older adults. Specifically, Black and Hispanic older adults whose income is slightly above the cutoff for Medicaid visit the doctor less often, fill fewer prescriptions and are less likely to get care for managing chronic conditions. One explanation for our finding is that Black and Hispanic older adults are less likely to have savings or alternative sources of supplemental insurance to pay for out-of-pocket health care costs.

Based on our findings, we suggest that increasing eligibility for Medicaid and reconfiguring Medicaid supplemental insurance so that assistance phases out gradually for those with modest incomes could help low-income Medicare beneficiaries get needed care. These changes would particularly benefit older adults of color, helping to address health care disparities in the Medicare program.

Healio: Will the end of the public health emergency widen racial and ethnic disparities in Medicaid?

Roberts: Our results are concerning as the COVID-19 public health emergency ends and states resume Medicaid eligibility determinations. Under the spending bill that President Biden signed into law last December, states will be required to reevaluate Medicaid eligibility for all current enrollees within the next 14 months. This includes 12.5 million older adults who receive Medicaid supplemental insurance.

A concern going into these renewals is that people are at risk of losing Medicaid — even if they still qualify — if they do not fill out renewal forms on time, or who are missing information to prove their income and assets remain low. Older adults who live alone or whose health is in decline may find this redetermination process particularly difficult, and there is a risk that these individuals could lose Medicaid.

Our results raise concerns that the loss of Medicaid may have harmful — and potentially inequitable — impacts on low-income older adults’ ability to pay for care. Monitoring changes in Medicaid coverage among low-income older adults, and policies to simplify redeterminations for this population will be critical over the next 14 months.

Healio: Is there anything else you’d like to add?

Roberts: Last year, President Biden signed into law the Inflation Reduction Act, which contains several measures to lower out-of-pocket drug costs for seniors. One of these measures expands the Medicare Part D “Extra Help” program, which provides financial assistance for low-income Medicare beneficiaries enrolled in Medicare Part D. While we applaud this change, we note that low-income Medicare beneficiaries may still have difficulty getting prescriptions if they cannot afford to see their doctor to get a prescription in the first place. Expanding Medicaid assistance for low-income seniors could help reduce these financial barriers to care among our nation’s seniors.

References:

• HHS reminds states of legal obligations to federal civil rights protections as states transition from Medicaid continuous coverage changes as the public health emergency ends. https://www.hhs.gov/about/news/2023/04/05/hhs-reminds-states-legal-obligations-federal-civil-rights-protections-states-transition-medicaid-continuous-coverage-changes-public-health-emergency-ends.html. Published April 5, 2023. Accessed April 11, 2023.
• Roberts ET, et al. JAMA Intern Med. 2023;doi:10.1001/jamainternmed.2023.0512.