End of COVID-19 pandemic ends Medicaid access for millions

More than 23 million Americans who were granted Medicaid coverage during the COVID-19 pandemic lost their coverage starting in March 2023 after the pandemic was declared no longer a public health emergency. Many likely will not successfully re-enroll on their own given Medicaid’s administrative burden—the frustrations and challenges people often encounter in seeking or complying with coverage.

Now, a study of the so-called Medicaid Great Unwinding by Simon F. Haeder, PhD, with the Texas A&M University School of Public Health, and a colleague from the University of Michigan, assessed how tolerant Americans are of administrative burdens in the wake of such a major policy event.

“One effort to address the pandemic pushed states to make enrolling in Medicaid much easier, which caused enrollment to surge to unprecedented levels—even more than introduction of the Affordable Care Act marketplaces,” Haeder said. “And while we know a great deal about public support of these policies, we knew very little prior to this about support of the administrative processes that can be difficult but that are often central to a policy’s success.”

For their study, published in Public Administration Review, the pair surveyed 4,074 Americans from Dec. 21 to Dec. 28, 2022, (before the unwinding) and 3,932 from Aug. 18 to Aug. 19, 2023, (as the unwinding took place). The surveys asked for opinions about five policies that lowered the cost of Medicaid enrollment by shifting the administrative burden from the individual to the state. Examples were the use of automatic renewals, pre-filled forms, contact information taken from other sources, improving processes for transferring Medicaid accounts and ensuring enough administrative capacity to perform these tasks.

The surveys also asked for opinions about four policies aimed at improving outreach and communication, such as communicating Medicaid information through nontraditional platforms and using plain language in materials explaining how to begin and end enrollment.

Respondents also were asked whether the burden-reducing measures taken on (or that should have been taken on) by the state during the pandemic should remain with the state or if these measures should return to individual beneficiaries, as was the case before the pandemic. Both surveys also contained experiments to find out if focusing on the detrimental and inequitable effects of increasing the administrative burden during the unwinding would affect public opinion.

“The responses for both surveys were remarkably similar despite the loss of Medicaid coverage for millions, and our experiment that emphasized these losses and how they could get worse had no effect on responses,” Haeder said. “We found broad support for burden reduction.”

While support was bipartisan, those who expressed empathy toward others, who were less able to handle administrative tasks or who had negative experiences with such tasks, and who viewed the burden as a form of systemic racism, had less burden tolerance, while those who express conservative beliefs or racial resentments had higher tolerance In addition, these ideological divisions grew stronger over time, and women generally became less tolerant of burdens over time.

“Americans want their state governments to reduce Medicaid’s administrative burden so that more eligible people can enroll,” Haeder said. “And while some state governments did better than others in reducing this burden during the pandemic, overall the Great Unwinding reflects how the health equity gap has widened post-pandemic.”