Investigating the Unwinding of Continuous Medicaid Coverage During the COVID-19 Pandemic

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After the start of the COVID-19 pandemic in 2020, the US government declared a public health emergency, and the individual states provided continuous Medicaid coverage to enrollees. Not only did the Families First Coronavirus Response Act grant states additional Medicaid funding, the states were also not allowed to remove patients from Medicaid due to eligibility redeterminations.^1,2

However, this changed by April 2023, when the mandated coverage concluded. At that point, states recommenced eligibility redeterminations via a process known as the “unwinding” of continuous Medicaid coverage.^1-3 Concerns were raised by stakeholders regarding the effect that this would have on access to care, specifically among pediatric patients, who represented a subgroup in which 40% of them are covered by Medicaid.⁴ In fact, as of October of last year, there was a net decrease of 14.7 million Medicaid beneficiaries, and one-third of those (>5.5 million) were children.⁴

Aside from the patient-level impact, unwinding is also believed to negatively impact health centers that serve Medicaid-insured groups, including 1 in 9 pediatric patients who are cared for by community health centers.⁵

As a result, a cohort study published in JAMA Network Open⁴ sought to further explore this unwinding of continuous Medicaid coverage among pediatric patients at these community healthcare organizations.

With the statistical analysis taking place in November 2024, the study featured electronic health record (EHR) data from OCHIN, a nonprofit organization containing a network of community-based healthcare organizations. Being that the focus was on pediatric patients, their maximum age was 17 at the time of their last visit during the period when Medicaid coverage was continuous (Jan. 1, 2021-March 31, 2023), and at their first visit during the unwinding period (April 1, 2023 to March 31, 2024).

Of the 450,146 participating pediatric patients, the mean (SD) patient age was 8.11 (5.07) years, with 50.1% of them being male. Further, 8.7% were disenrolled from Medicaid to uninsured status. The highest estimated disenrollment among age groups belong to patients aged 12 to 17 years (10.5%), but all other age groups had lower odds of disenrollment compared with those younger than 1 year (following adjustment).

Females had higher odds of disenrollment (adjusted odds ratio [AOR], 1.15 [95% confidence interval, or CI, 1.13-1.18]; adjusted hazard ratio [AHR], 1.14 [95% CI, 1.12-1.17]) than males. Meanwhile, 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 an estimated disenrollment of 17.1% vs 9.4%.

And when compared alongside 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 chances of disenrollment.

“In this cohort study of systemically underserved pediatric patients who received care from frontline primary care health care organizations, we identified that during the unwinding of continuous coverage provisions, many pediatric patients were disenrolled from Medicaid to uninsured status,” concluded the study investigators. “Future work should continue to examine the impact of this disenrollment to uninsured status on patients’ access to care and health outcomes and clinic operations.”

References

1. Tolbert J, Ammuula M. 10 Things to know about the unwinding of the Medicaid Continuous Enrollment Provision. Kaiser Family Foundation. June 9, 2023. Accessed June 26, 2023. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/

2. Wilkle S, Wagner J. Unwinding the Medicaid continuous coverage requirement. Center on Budget and Policy Priorities. Updated April 8, 2023. Accessed March 15, 2024. https://www.cbpp.org/research/health/unwinding-the-medicaid-continuous-coverage-requirement

3. Wagner J, Erzouki F. Time to get it right: state actions now can preserve Medicaid coverage when public health emergency ends. Center on Budget and Policy Priorities. May 1, 2022. Accessed March 15, 2024. https://www.cbpp.org/sites/default/files/5-18-22health.pdf

4. Bensken WP, Dankovchik J, Fein HL, Duhon G, Sills MR. Unwinding of Continuous Medicaid Coverage Among Pediatric Community Health Center Patients. JAMA Netw Open. 2025;8(2):e2458155. doi:10.1001/jamanetworkopen.2024.58155

5. National Association of Community Health Centers. Community Health Center Chartbook 2024: analysis of 2022 UDS data. March 1, 2024. Accessed December 18, 2024. https://www.nachc.org/resource/community-health-center-chartbook/