Unwinding of Continuous Medicaid Coverage Among Pediatric Community Health Center Patients.

Abstract

Importance: During the COVID-19 pandemic public health emergency, states provided continuous Medicaid coverage to enrollees. In April 2023, states began to unwind this continuous coverage, prompting concern about the impact of this on pediatric patients.

Objective: To examine loss of coverage during the unwinding of continuous Medicaid coverage among pediatric patients seen at community-based health care organizations.

Design, setting, and participants: This cohort study with statistical analysis in November 2024 included pediatric patients from a multistate network of community-based health care organizations. Participants were aged up to 17 years at both their last Medicaid-insured visit during the continuous coverage period and at their first visit during the unwinding period (April 1, 2023, to March 31, 2024).

Exposures: Age, sex, race and ethnicity, language, and medical complexity.

Main outcome and measures: The main outcome was Medicaid disenrollment to uninsured status during the unwinding period. Logistic regression was used to estimate the odds of ever being uninsured during unwinding, and Cox proportional hazards regression models were used to examine the time to uninsured status from the start of unwinding in each patient's state of residence through the end of March 2024. Associations between age, sex, race and ethnicity, language, and medical complexity and the outcome were assessed.

Results: Among 450 146 pediatric patients, mean (SD) patient age was 8.11 (5.07) years and 50.1% were male. Overall, 8.7% were disenrolled from Medicaid to uninsured status. Patients aged 12 to 17 years had the highest estimated disenrollment among age groups (10.5%), but after adjustment, all other age groups had lower odds of disenrollment compared with those younger than 1 year. Females had higher odds of disenrollment (adjusted odds ratio [AOR], 1.15 [95% CI, 1.13-1.18]; adjusted hazard ratio [AHR], 1.14 [95% CI, 1.12-1.17]) than males. American Indian or Alaska Native patients had higher odds of disenrollment (AOR, 1.95 [95% CI, 1.81-2.09]; AHR, 1.81 [95% CI, 1.05-3.13]) than White patients, with estimated disenrollment of 17.1% vs 9.4%. Compared with patients with low medical complexity, those with either chronic but noncomplex (AOR, 1.83 [95% CI, 1.79-1.88]; AHR, 1.80 [95% CI, 1.44-2.27]) or complex chronic (AOR, 1.95 95% CI, 1.89-2.00]; AHR, 1.92 [95% CI, 1.67-2.21]) medical complexity had higher odds of disenrollment.

Conclusions and relevance: In this cohort study of previously Medicaid-insured pediatric patients seen at community-based health care organizations, a meaningful proportion of patients were disenrolled to uninsured status during the unwinding of continuous Medicaid coverage, with associated differences by demographic and clinical characteristics. This could impact access to care and health outcomes for the patients.