Boston University School of Public Health: During COVID-19, Majority of Newly Unemployed Adults in North Carolina Didn't Receive Medicaid

BOSTON, Massachusetts, Oct. 15 (TNSJou) -- Boston University School of Public Health issued the following news:

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Only 15 percent of adults who became unemployed and uninsured during the pandemic actually enrolled in Medicaid, and the enrollment rate was highest in the state's most socially vulnerable counties.

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By Jillian McKoy

Within the first few months of the pandemic, the US unemployment rate skyrocketed from 3.8 percent in February 2020 to 13 percent in April 2020, quickly surpassing total job losses from two years of the Great Recession. Millions of people who were forced out of the workforce lost both income and employer-sponsored health insurance coverage.

Medicaid was designed to help absorb the shock of economic hardship, particularly during a crisis such as COVID-19. But for many people who lost their jobs and health insurance during the pandemic in North Carolina--one of 12 states that did not expand Medicaid under the Affordable Care Act--the safety net health insurance program was unable to fully meet economic need in a crisis, according to a new study led by a School of Public Health researcher.

Published in the journal Health Affairs, the study found that only 15 percent of North Carolina residents who became unemployed and uninsured during the first three months of the pandemic actually enrolled in Medicaid. Among the 12 nonexpansion states, North Carolina maintains some of the most restrictive Medicaid eligibility requirements.

"Our study results aren't surprising, given how difficult it is to qualify for Medicaid in North Carolina," says study lead author Paul Shafer, assistant professor of health law, policy & management. "Essentially, if you're an adult without children or other dependents, you can never qualify for Medicaid based on income alone. Parents and caregivers who do qualify can only earn income up to 41 percent of the federal poverty level (FPL), which is very low relative to expansion states, where everyone up to 138 percent of the FPL can qualify."

Studying county-level data on unemployment, Medicaid enrollment, and social vulnerability, the researchers also found that the most socially vulnerable counties in North Carolina had the highest gains in Medicaid enrollment--good news, says Shafer, but not good enough, considering the state's high uninsurance rate overall: an estimated 20 percent of adults in the state became uninsured by May 2020.

"It's not enough to say that we're moving in the right direction," says Shafer. "The idea that, in a post-ACA world, a state could have a 20 percent uninsurance rate among adults is mind-blowing. It's very clear that a substantial number of people are losing coverage and have nowhere to go for other health insurance."

The findings underscore the important role of social context in the relationship between unemployment and Medicaid enrollment. State-wide Medicaid data may not accurately capture differences in unemployment and other barriers to Medicaid enrollment that can occur within a state.

As the country moves closer to a post-pandemic reality, the gap between unemployment and uninsurance may only worsen, the researchers say. Millions of additional people are in danger of losing Medicaid coverage if a Congressional ban on removing anyone from Medicaid expires next year.

The obvious solution to ensuring people retain or acquire health insurance coverage is to expand Medicaid, says Shafer.

"Congress can make this problem largely go away by closing the Medicaid gap and pursuing strategies such as auto-enrollment, which will dramatically reduce the administrative burdens that eligible people face," he says.

The study's senior author is Brad Wright, associate professor in the Department of Family Medicine at the University of North Carolina Chapel Hill. Co-authors, all of Duke University's Duke-Margolis Center for Health Policy, include research associate David Anderson; managing associate Rebecca Whitaker; and associate professor of pediatrics and public policy Charlene Wong.

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JOURNAL: Health Affairs https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2021.00377?journalCode=hlthaff