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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 podocy. I'm your host, Rob Lott. During the pandemic, congress passed a law that said to states, we'll increase the federal share paid for Medicaid and CHIP if you implement continuous enrollment, a policy where once someone is enrolled in Medicaid, they can't be kicked off as long as there's still this public health emergency in place. This led to a boost in coverage, which was especially vital during the depths of COVID's darkest days. But when the public health emergency ended on 03/31/2023, states could go back to their old policies requiring people to renew their Medicaid enrollment every year and removing from the roles those who were no longer eligible.
Rob Lott:That process has been called the unwinding And at the time, many researchers, policymakers, and advocates raised the alarm that it would lead to a dramatic loss in coverage across the country. Now, two years later, the question remains, was that prediction accurate? Did we see a significant rise in the number of uninsured Americans? That's the topic of today's Health Odyssey. I'm here with Doctor.
Rob Lott:Thomas C. Buck Mueller, Professor of Business Economics and Public Policy at the University of Michigan, and a visiting fellow at the Brookings Institute. From 2023 to 2025, Doctor. Buck Mueller served as Deputy Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services. Together with his coauthors, Doctor.
Rob Lott:Buck Mueller has a new paper in the May 2025 issue of Health Affairs. Its title is also its main finding. Quote, during Medicaid unwinding, much of the reduction in Medicaid paid prescriptions was offset by increased commercial coverage. So let's just dig in here and find out why that's significant. Doctor.
Rob Lott:Thomas Buckmuller, welcome to the podocy.
Thomas Buchmueller:Thanks for having me.
Rob Lott:So let's start at the beginning. I in in my introduction, I sort of gave little overview of the unwinding. How did I do? Did I give a good sense of what was going on Awesome.
Thomas Buchmueller:You get an a.
Rob Lott:Awesome. Thank thank you, professor Buckner. Can you put us in in the timeline in March 2023 what people were predicting about the unwinding?
Thomas Buchmueller:Yeah. I think, at the time and and during, you know, that first year or so, there was an understandable concern that people were gonna be rolling off of Medicaid and becoming uninsured, losing coverage. And so we were tracking this, without a lot of great data. So states were reporting, monthly information on disenrollment, but that wasn't even giving us a complete picture of what was going on with Medicaid because in any month you have people who are disenrolling and you have other people who are coming on to the program and in some cases they're the same people. Know someone would be a bit disenrolled and then you know submit their application and get back on.
Thomas Buchmueller:So so people, I think, were very alarmed when they saw a large number of of people being disenrolled. A lot of them were so called procedural disenrollments where maybe somebody forgot to or just didn't put in their their paperwork. But we didn't know what was going on with coverage overall. And generally, we track health insurance coverage using federal surveys like the National Health Interview Survey, the American Community Survey, and those data sets are available with a considerable lag. So there just wasn't great real time data on what was happening.
Rob Lott:Okay. Well, so let's talk about your research paper. You look specifically at who was paying for prescriptions for patients after the unwinding. Why did you, look at that versus some other kind of spending?
Thomas Buchmueller:We looked at prescription data for a
Rob Lott:couple
Thomas Buchmueller:reasons. One is the fact that the the data source we use, which is from IQVIA, is available more quickly than other sources of data. So we have quarterly data that was available pretty quickly after the end of the quarter. And the IQVIA data has a very good coverage, so it's national in scope and basically is capturing all prescription drugs in the country. So we thought we could infer something about changes in coverage from changes in prescription fills.
Thomas Buchmueller:But then we also were interested in prescription drugs directly because obviously the reason we care about people having insurance coverage is so they can get access to the care they need. And roughly half of Americans use prescription drugs every month, And so this was going to tell us if during the unwinding people were losing access to valuable care.
Rob Lott:Okay. So you've got this sort of clever, end run around the lag, a way to maybe get a sense of things sooner than you would otherwise. What did your research show? What are some of the top line findings?
Thomas Buchmueller:Yeah, so we looked at a few different outcomes. So first of all, we wanted to convince ourselves that the prescription drug data, did track Medicaid enrollment. So we compared trends in, Medicaid paid fills with the Medicaid enrollment data And and overall the data tracked pretty well. So during the period of the the public health emergency when the continuous enrollment provision was in effect, both Medicaid enrollment and Medicaid filled prescription paid fills sort of went up continuously. And then if you look at the end of, you know, the start of the unwinding period, both of those started to fall.
Thomas Buchmueller:So we did some estimates, four quarters after state began unwinding, Medicaid enrollment was down by about 37%. Medicaid paid fills were down a little bit less like about 22%, but but the general trend, was similar. So so that told us that we were capturing something that was going on with enrollment. So then the question is what happened to the total number of prescriptions filled? The obvious concern is that if people are losing coverage, then they are not going to be able to afford the medicine they need, we're going to see a decline in prescriptions.
Thomas Buchmueller:So we looked at we we took the data and we aggregated Medicaid, fills, commercial insurance, and cash fills. We we did not look at Medicare Part D, and we looked to see how that trended after states began unwinding. And we saw very little change so there was a slight decrease in total fills but it was less than 1%, it was not statistically significant. So that gave us comfort that at least people were not forgoing the prescription drugs because they lost coverage. The question is we know that Medicaid fills were going down, total prescriptions were not changing, How are people paying for their prescriptions?
Thomas Buchmueller:So the last part of the analysis, we, we broke it down by payer source. And what we found was there was an increase in prescriptions that were purchased with commercial insurance. And the size of that increase was about 86% as large as the decrease in Medicaid. So it looks like most people, were transitioning to private insurance. We saw a slight increase in the number of prescriptions, paid for with cash, but it was very small relative to the change in Medicaid prescriptions.
Thomas Buchmueller:So overall, the data seem to suggest that people were successfully transitioning from Medicaid coverage to some form of private coverage.
Rob Lott:Okay, so what factors can we potentially attribute this shift to commercial coverage to? In other words, what, you know, what allowed folks to move into commercial coverage?
Thomas Buchmueller:So I think the biggest, explanation is the growth in coverage through the ACA marketplace. So I should say, a limitation of our data is that we don't have we can't break out, marketplace coverage from employer sponsored insurance coverage, but there's a lot of other data sources that suggest that that it's an increase in marketplace coverage that was driving it. So first of all, we know that over this period between 2020 and 2024, marketplace coverage almost doubled. It went up from about 11,000,000, people to over 21,000,000 people. And we know from from other work that's been published in health affairs that, using the the Census Bureau's household pulse survey, gave sort of rapid data, on what was going on for adults at least, there seems to be some transition from Medicaid to to marketplace coverage.
Thomas Buchmueller:And and there's, you know, good policy reasons why marketplace coverage was increasing. So, number one, it was much more affordable, you know. So as part of the American Rescue Plan in 2021, the Inflation Reduction Act of 2022, the the size of the the tax credits that people had to buy marketplace coverage increased dramatically, and and more people had access to these credits. So so marketplace coverage is becoming more affordable, and the Biden administration was doing a number of things to make it easier for people to enroll in the marketplaces. So they established, special enrollment periods for people who were were leaving Medicaid during the unwinding, special enrollment periods during the the pandemic, for people who lost their coverage, special moment period for people with low income.
Thomas Buchmueller:And, they also invested heavily in outreach, through navigators, you know which are nonprofit organizations that help people find coverage and sign up for a plan that's right for them. So all these things together I think made marketplace coverage more accessible and more affordable and that helped people make a smooth transition from Medicaid to private coverage.
Rob Lott:Great and just a minute I want to ask you about what that says about our earlier predictions Before we do though, let's take a quick break. And we're back. I'm here with Doctor. Thomas Buckmiller discussing his paper about the Medicaid unwinding. So just a moment ago, you gave a great overview of the factors that attributed, factors that we can attribute to the shift toward commercial coverage.
Rob Lott:I'm wondering if you can put us in your shoes when the the first time you ran your numbers and you saw that shift, were you surprised at that time?
Thomas Buchmueller:We were a little surprised.
Rob Lott:Yeah.
Thomas Buchmueller:There were some studies that have been done, during the the the public health emergency using earlier data to try to project out what the coverage effects would be when the unwinding started and they were predicting a pretty sizable increase in number of uninsured people. And we have other research that shows that insurance coverage has a large effect on prescription drug use. We were expecting to see a decline in total fills and maybe even an increase in the number of fills that were paid for with cash.
Rob Lott:So, you know, we talked about the, you know, folks raising the alarm in 2023 about the potential effect, and there's a bit of a discrepancy here between what we feared perhaps and what the reality is. What do you think explains that gap?
Thomas Buchmueller:So I think there's a couple of explanations. One is that the projections were were based on, pre pandemic data when the tax credits for for marketplace coverage were less generous, when, there was less funding for, outreach navigators. And so I think that they really couldn't properly account for how much marketplace coverage was gonna increase. So that's kind of the most substantive, you know, policy oriented, explanation. But there's also a measurement issue.
Thomas Buchmueller:There's always been a disconnect between, Medicaid coverage as it's measured in enrollment data, administrative data, and as it's measured in surveys. It's called the Medicaid undercount. And the Medicaid undercount grew during the public health emergency, and the best explanation is that, you know, as people left Medicaid to go on to private insurance, they still will be counted in the in the administrative data, but they when they answered the survey, they said they had private insurance. And other people, didn't realize they were still covered. And so when they answered the survey, they said that they were uninsured when they were showing up in in the administrative data as as having Medicaid.
Thomas Buchmueller:And so a lot of those coverage changes were already baked in, and so we we don't see that much of a change in the survey data, because the measurement error increased and then decreased, as we returned to kind of normal.
Rob Lott:Gotcha. Is that something that sort of lesson we can learn from that discrepancy, is that something that, might be relevant to future research questions? Can you imagine researchers asking a similar question ten years from now and saying, oh, don't forget what happened back during the pandemic. Is there a relevance to this finding going forward?
Thomas Buchmueller:Yeah, I think there's a relevance both in terms of how we measure coverage and how we as researchers how we track it, but then also for states as they communicate with enrollees because if somebody is enrolled in Medicaid and they don't realize it then they're not going get the full benefits of that coverage so it's why I think there's a more a real reason to do a better job of making sure people understand what coverage they have.
Rob Lott:Great. And that's perhaps a good segue for my next question, which is to imagine your paper in the hands of a member of Congress or their staffer, or perhaps someone at the state level in a state Medicaid office. They read your paper, they understand it and then they maybe they say to you, so what? The unwinding has already happened. Let's just be more, you know, let's just be grateful more people than end up uninsured.
Rob Lott:Can you say a little more about how you might explain the applicability of your your findings to potential future policy making decisions?
Thomas Buchmueller:Yeah. Well, I think that the the experience during the, continuous enrollment period, is important because, you know, now all states are required to provide twelve months of continuous enrollment for kids. A number of states are going well beyond that to provide continuous enrollment for kids up to age six. And so it's going be really important that families understand what coverage they have available to them and, you know, make sure they know what they're still covered even if their circumstances change. So that's a very, kind of, operational aspect that I think is very important.
Thomas Buchmueller:But then if you think about the explanation for why we think things went so smoothly during the unwinding, it's all about the marketplaces. You know? So so the enhanced tax credits, made marketplace coverage significantly more affordable. Those enhanced tax credits are scheduled to expire at the end of this year. So if congress doesn't act, individual coverage in The US is gonna get a lot more expensive.
Thomas Buchmueller:It's it's probably the case that navigators and all the things that the administration did to, improve information about the marketplaces to help people sign up played an important role in in helping people make those transitions. Well, the Trump administration has already dramatically cut back funding for navigators. And the special enrollment periods allowed people to to sign up, outside of the normal open enrollment period. And I think we saw a lot of, you know, during the unwinding, a lot of people signing up outside of the open enrollment period, in in a proposed rule that was recently issued, the administration is looking to to greatly reduce those special enrollment periods. So I think if you look at the marketplaces and all the things that are likely to happen in the next few months, we're gonna see, probably a significant reduction in marketplace coverage and a significant increase in number of people who are uninsured.
Thomas Buchmueller:So that that's something that I think, you know, policymakers really should be looking at.
Rob Lott:Okay, well a great agenda for future research as well, and perhaps a good place for us to wrap up today. Doctor. Thomas Buckmiller, thank you so much for taking the time to chat with us. This was a lot of fun.
Thomas Buchmueller:No, thank you. I enjoyed it.
Rob Lott:And to our listeners, thanks for tuning in. If you enjoyed this episode, tell a friend, smash that subscribe button, and tune in again next week.
Thomas Buchmueller:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.