Subscribe
Share
Share
Embed
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Odyssey. I'm your host, Rob Lott. When it comes to programs like Medicaid and CHIP, the Children's Health Insurance Program, one of the thorniest challenges is churn. That is the temporary loss of coverage in which enrollees disenroll and then reenroll within a short period of time, often due to an individual's changing status and eligibility, as well as potential administrative hurdles, like paperwork and filing requirements. Some studies have shown churn rates as high as ten percent for children on Medicaid and CHIP in recent years.
Rob Lott:Of course, this problem is not impossible. One of the most effective policy interventions aimed at reducing coverage loss is known as continuous coverage or continuous eligibility. This is where essentially, once the child is enrolled, they're good to go for a full twelve months. They're not going to be kicked off. They're not going to have their eligibility reassessed or redetermined.
Rob Lott:States have had the option of offering continuous eligibility as far back as 1997, but only some have chosen to do so. That changed with some pandemic era policy shifts, then changed again after the pandemic, and then changed once more in 2024. What can we learn from all of these policy shifts about the best ways to maintain children's coverage and, ultimately, to ensure those kids can get the care and stability they need to grow and thrive. That's the subject of today's health policy. I'm here with doctor Erica Eliasson, assistant professor in the department of urban global public health at Rutgers School of Public Health, together with her coauthors, Daniel Nelson and Aditi Vasan.
Rob Lott:Doctor Eliasson has a fascinating new article in the March issue of Health Affairs examining the effect of continuous eligibility policies and chip structure on children's coverage loss during the so called Medicaid unwinding. There is so much to learn from their findings, so let's just get into it. Doctor Erica Eliasson, welcome to Health Odyssey.
Erica Eliason:Thank you for having me.
Rob Lott:Let's maybe, take a step back, start with some some context from from pre pandemic. What was the status of continuous eligibility provisions across the states before COVID, and then how did the sort of COVID era flexibility change things?
Erica Eliason:As you mentioned briefly, even before the the pandemic policy changes, states had the option to offer twelve months of continuous Medicaid eligibility, for children, which allowed them to keep that coverage for a year even if there were changes in their eligibility during that time. So before the pandemic about half of states had this policy option in place for children at the 12 level but then in response to the public health emergency there was the Families First Coronavirus Response Act which offered states enhanced federal funds in exchange for the continuous enrollment of Medicaid beneficiaries. So that policy was in place starting March 2020 until 2023, April '20 '20 '3 which is when states could start rolling back that policy. So from, that twenty twenty to '20 '20 '3 period, all Medicaid enrollees had continuous Medicaid coverage.
Rob Lott:What do we know about the effect of continuous eligibility on people's health and well-being?
Erica Eliason:Research from the twelve month continuous eligibility policies for children prior to the pandemic policies, found that continuous eligibility increases coverage stability, decreases unmet health care needs and improves health outcomes. Then some work has found that this has even greater improvements for some children like children with special health care needs who have more ongoing demands for medical care so they might particularly benefit from having that continuous enrollment.
Rob Lott:Gotcha. Now, there's another element here that, your paper delves into, which is that different states structure their CHIP programs in different ways. Can you say a little more about those differences and, how that comes into play here?
Erica Eliason:So there are about, I guess, three structures that states tend to use for their CHIP programs. So the first one is building off of the Medicaid program that they have. And that's referred to as a Medicaid expansion chip so those children get all the same benefits that they would in Medicaid. But if states take a different approach where they offer it as a totally separate type of insurance which is called separate CHIP then states have more flexibility in the design of their CHIP insurance. And then the third option is a combination approach referred to as combination CHIP where they have some elements of, the Medicaid expansion CHIP and then some, separate CHIP as well.
Rob Lott:Gotcha. Okay. And do you have a sense of, how that breaks down from state to state? What's sort of the most common structure?
Erica Eliason:Oh, yes. A combination chip is the most common. And then at the time of the unwinding, there are only two states that had just a separate chip. The continuous coverage policy that was in place during the pandemic did not apply to separate chip.
Rob Lott:Gotcha. Okay. Alright. So alright. Now, tell us a little bit about the unwinding.
Rob Lott:When did that take place, and what did it mean for continuous eligibility?
Erica Eliason:Yeah. So, the unwinding process, means that states were able to start their Medicaid disenrollment procedures again. So, states were able to do this starting in April of twenty twenty three but they didn't all start in April 2023. There was a bit of a staggered rollout and the unwinding, the reinitiating of disenrollment was generally over around twelve months, but there's some state variation in that as well.
Rob Lott:Okay. So, your paper looked at this sort of this critical moment. The unwinding begins. Presumably, there's gonna be some coverage loss, as a result of the that process. And am I correct?
Rob Lott:Your paper basically looked at how much loss there was and how it varied according to which policies were in place before the pandemic as well as which CHIP structure was in place. Is that a fair description?
Erica Eliason:Yes. I looked at how, children's Medicaid and CHIP enrollment changed, as a result of the unwinding and then across states that had twelve month continuous eligibility or not for children in place prior to the pandemic and then CHIP structure.
Rob Lott:So what approach did you use to ask those questions?
Erica Eliason:Yes. Okay. So we used monthly Medicaid and CHIP enrollment data for children for states that they report to CMS and, is publicly available on the CMS website. And we use the period of January 2021, while the policy, the pandemic policy was in effect, through December 2023. So the unwinding period for that time was April 2023 to December 2023 but we took into account the different initiation start dates that states had and we used data for all states except for Arizona because Arizona did not report children's enrollment separately from adults enrollment.
Erica Eliason:So we did an interactive time series model so we were able to look at how enrollment changed in the first month of the unwinding for the state and then in the subsequent period, through December of twenty twenty three.
Rob Lott:And then give us some of the top line findings. What did you learn from that process?
Erica Eliason:The top line finding is that the unwinding was associated with declines in the proportion of children who were enrolled in Medicaid or CHIP. As we expected, there was coverage loss, from the unwinding and then there were differences significant differences by CHIP structure as well as significant differences by whether or not a state had a twelve month continuous eligibility policy. So by CHIP structure we found larger declines among states with combination CHIP compared to Medicaid expansion CHIP and then by continuous eligibility policy we found larger declines in states that did not have twelve month continuous eligibility for children compared to states that did have a twelve month continuous eligibility policies.
Rob Lott:Alright. That seems pretty clear. Next up, I'm hoping we can talk a little bit about the mechanisms behind these changes. But first, let's take a quick break. And we're back.
Rob Lott:I'm here with Rutgers University's doctor Erica Eliason, and we're talking about the impact of changes in continuous eligibility policies post pandemic. So, doctor Eliason, you found differences in the coverage losses by state. I'm wondering if you can say a little bit about in your at least theoretically, what explains those differences.
Erica Eliason:During the, pandemic policy, states that did not have twelve month continuous eligibility already for children saw, more increased coverage than states that had twelve month continuous eligibility because those states were newly implementing continuous eligibility they saw greater benefits than states that already had twelve month continuous eligibility. Although of course the continuous eligibility during the pandemic was over a longer period of time so states that had twelve month continuous eligibility did benefit just past the point that the states that were newly implementing continuous eligibility altogether. So the larger gains in the states that were newly implementing continuous eligibility indicate that those children were more influenced by the pandemic policy so as a result when the pandemic policy was rolled back we did find that children there were at more risk of losing this coverage that had been gained.
Rob Lott:Got it. So, essentially, states where there was more room to gain also, perhaps had a greater risk of loss on the other side of the pandemic.
Erica Eliason:Exactly.
Rob Lott:Okay. So after all of this, congress passed national mandatory twelve month continuous eligibility for children in Medicaid and CHIP under the, Consolidated Appropriations Act of 2023, and that took effect in January 2024. So after the unwinding, after your period of analysis. And so I guess this raises the question, does this basically render your research a sort of artifact of history? I I don't wanna call it obsolete, but, what is the, sort of, the relevance of that period to where we are today?
Rob Lott:What are the lessons from the unwinding that can still be applied in this new era under this new requirement?
Erica Eliason:Yeah. So I wouldn't say it's obsolete. So one thing to note is, as of January 2024 all states had to adopt twelve month continuous eligibility for children, but the unwinding was still happening in some states during that time. So what we would expect from that is that that new twelve month continuous eligibility period will dampen children's coverage loss in those states that are reimplementing continuous eligibility. We won't really expect effects in the states that already have the twelve month continuous eligibility, but, we do expect that the states that are reimplementing continuous eligibility will see less coverage loss for children, as they reimplement the policy.
Rob Lott:Gotcha. Okay. So let's say you get a call from a state Medicaid director, this afternoon, and they're doing some strategic planning for the next few years, all the uncertainty of the current policy universe aside, and they've read your paper. It seems pretty important to their work, but they're sort of having some trouble factoring it into their plans for 2026 and beyond. What would you recommend?
Rob Lott:How would you say they should read your paper? Through what lens would you recommend they view your article?
Erica Eliason:So overall, what we found was, you know, unsurprising that the unwinding led to lower Medicaid and CHIP enrollment among children. But, I do think the fact that twelve month continuous eligibility policies were protective against some coverage loss for children is still important since the implementation of those policies, nationally under the CAA, occurred while states were still completing their unwinding. So, we would expect a flattening out of coverage loss in those states. And I expect that children in states newly implementing those twelve month continuous eligibility policies will see benefits from this policy even though there was the previous pandemic era policies. The other takeaway that is still relevant moving forward is about the CHIP structure piece.
Erica Eliason:So some states in preparation of the unwinding had actually transitioned to Medicaid expansion CHIP to try to reduce enrollment barriers and our study finds that this may have been protective against coverage loss for children so this approach was successful because Medicaid expansion chip is the one that built off Medicaid programs so there's more, Medicaid chip integration there. I do think an overall takeaway from all this is that the continuous enrollment periods work to improve, children's Medicaid and chip coverage.
Rob Lott:Your paper alludes to multiyear continuous eligibility as a potential policy option in the future. What can you tell us about that? How likely is that to take effect in some of these states?
Erica Eliason:The most recent report I had seen was that 13 states are implementing or pursuing multi year continuous eligibility, which is primarily for young children, in most states age zero to five. And so because the pandemic policy was in place 2020 to 2023, the multi year continuous eligibility in those 13 states would more closely follow the the coverage patterns that children had during the pandemic, as opposed to just the twelve month continuous eligibility, which is just for, one year. So I actually think that there's a lot that we can learn from the pandemic continuous eligibility to inform multi year continuous eligibility including how that affected children's health care access, things like unmet health care needs, health care use, and things like administrative burden. And I I do have some work underway looking at, the implications of the pandemic policy, for some of those outcomes. Other work I think, will be interesting moving forward is looking in those states that are implementing multi year continuous eligibility compared to the states that just keep the twelve month continuous eligibility.
Erica Eliason:So you know how does that affect children's coverage for long periods, health health care outcomes, and for which children, you know, going back to research that found that children with special health care needs may benefit more from continuous eligibility policies. So, how children with special health care needs in those states, how their health care changes, or other children who are more likely to experience coverage loss prior to all of this, like Hispanic children, they could potentially see, larger gains, than other groups. And then, very, very long term, I think it will be interesting, to look at any long term health effects, later in life, that could last into adulthood.
Rob Lott:Okay. I wanna say thank you, doctor Eliasson for taking the time to, to be here and, share your findings with us.
Erica Eliason:Yeah. Thanks so much.
Rob Lott:To our listeners, thanks so much for tuning in. If you enjoyed it, please recommend it to a friend. Smash that subscribe button and tune in next week. Thank you. Thanks for listening.
Rob Lott:If you enjoyed today's episode, I hope you'll tell a friend about a healthy policy.