Expert Commentary

Pandemic provisions reduced loss of Medicaid coverage for beneficiaries enrolled in both Medicaid and Medicare, study finds

During the COVID-19 public health emergency, temporary policy changes significantly narrowed racial disparities in Medicaid coverage loss among dual-eligible beneficiaries.

(Illustration by generative AI technology DALL-E, with directions from Naseem Miller.)

The loss of Medicaid coverage among Americans eligible for both Medicare and Medicaid — known as dual-eligible beneficiaries — was substantially reduced during the COVID public health emergency due to temporary policy changes, according to a study published in JAMA Network Open this month.

More importantly, those policy changes, which prohibited the states from disenrolling people from Medicaid, reduced and to some extent eliminated the pre-pandemic racial disparity in Medicaid coverage loss.

“Our study sheds light on the challenges that Medicaid enrollees generally faced in maintaining continuous Medicaid coverage prior to the [public health emergency], and the challenges that will likely re-emerge with the resumption of Medicaid redeterminations in 2023,” Dr. Yanlei Ma, the study’s lead author and a research associate at the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health, wrote in an email to The Journalist’s Resource.

The study, “Medicaid Eligibility Loss Among Dual-Eligible Beneficiaries Before and During COVID-19 Public Health Emergency,” analyzed national Medicare data from 2015 to 2020, tracking 56.2 million yearly records of beneficiaries who were eligible for both Medicare and Medicaid.

The authors focused on dual-eligible beneficiaries “because they represent a particularly vulnerable segment of the health care population, often facing complex health needs and socioeconomic challenges, which can complicate their access to necessary healthcare services,” Ma wrote. “Notably, dual-eligibles account for approximately one-third of spending in the Medicare and Medicaid programs despite representing only 20% of Medicare and 15% of Medicaid beneficiaries.”

About 12.5 million people in the U.S. are enrolled in both Medicare and Medicaid due to their age or disability and low income. This dual-eligible population mostly includes people with chronic conditions, physical disabilities, mental illness and cognitive impairments such as dementia and developmental disabilities.

Medicare is the federal health insurance program for people who are 65 years or older, certain younger people with disabilities and people with kidney failure requiring dialysis or a transplant. More than 65.7 million people are enrolled in Medicare.

Medicaid is a joint federal and state program that covers the health care costs of certain low-income individuals and families, qualified children and pregnant women, and people 65 years or older who are blind or disabled and have limited income. It’s also the main payer for long-term services. Medicaid is the largest source of health coverage in the U.S. with nearly 78 million enrollees.

For dual-eligible beneficiaries, Medicare pays first for the Medicare-covered services that are also covered by Medicaid. Medicaid covers services that Medicare does not cover, according to, which has a chart detailing what each program covers.

In 2020, 87% of dual-eligible beneficiaries had an income less than $20,000; 40% were under age 65; 49% were people of color; and 44% were in fair or poor health, according to a 2023 report by KFF, formerly the Kaiser Family Foundation.

While dual-eligible beneficiaries remain continuously enrolled in Medicare, many face the risk of losing Medicaid coverage each year due to various factors. These may include income fluctuations, changes in states’ Medicaid eligibility and, notably, administrative barriers, including onerous paperwork related to the Medicaid redetermination process, according to the study.

Before the pandemic, the proportion of beneficiaries who lost Medicaid for at least one month rose from 6.6% in 2015 to 7.3% in 2019, the study finds. Also, Black and Hispanic beneficiaries were more likely to lose Medicaid than their white peers, the authors find, highlighting that administrative barriers can disproportionately affect people of color.

Ma listed several reasons that contributed to the increasing rate of Medicaid loss between 2015 and 2019, including changes in the states’ eligibility criteria and budget pressures, which might have led some states to look for ways to reduce Medicaid enrollment as a cost-saving measure.

But those trends were reversed in 2020.

The proportion of dual-eligible beneficiaries who lost Medicaid for at least one month dropped to 2.3%, representing hundreds of thousands of individuals who retained their coverage, the study finds.

The study also finds more than half of dual-eligibles who lost Medicaid coverage during the study period subsequently regained their Medicaid coverage within one year.

“This suggests that the coverage losses are less likely due to sustained changes in eligibility but rather administrative factors,” Ma wrote in an e-mail. “Eligible individuals might lose Medicaid if they fail to receive, comprehend, or respond timely to notices or forms requesting additional information.”

Ma and co-authors warn that the end of the public health emergency in May 2023 — and with it, the return to regular Medicaid eligibility redeterminations — could lead to a resurgence of coverage losses. Ma noted that this concern applies to all Medicaid beneficiaries.

Starting in April 2023 states resumed the process of redetermining Medicaid eligibility, also known as “Medicaid unwinding,” which requires beneficiaries to complete paperwork and provide proof of continued eligibility.

As of April 18, at least 20.3 million Medicaid and CHIP (Children’s Health Insurance Program) beneficiaries across the country have been disenrolled from the program, according to KFF, which has been tracking Medicaid unwinding. That’s 22% of 94 million Medicaid and CHIP enrollment in March 2023, a month before Medicaid unwinding began.

“As states have resumed Medicaid redeterminations, there is a pressing need for policymakers to implement strategies to minimize Medicaid coverage losses, especially for the most vulnerable and minoritized populations,” Ma and co-authors write in the study.

They recommend that the Medicaid eligibility of dual-eligible beneficiaries be determined from data from other programs such as the Supplemental Nutrition Assistance Program. They also recommend allowing enrollees more time to respond to additional information requests, allocating more resources and personnel to process eligibility determinations, and providing enrollment materials that are accessible to people with limited English proficiency or disabilities such as vision impairment.

The authors plan to continue this research to document the disenrollment trends as states resume Medicaid redeterminations after the end of the public health emergency, Ma wrote.

Additional resources

  • Ma delves deeper into the special needs of dual-eligible beneficiaries in this 2023 Health Affairs podcast, including homelessness, lack of transportation or food insecurity.
  • A 2019 study published in Health Affairs finds that between 2012 and 2016, 18.2% of Medicare beneficiaries receiving full or partial Medicaid were disenrolled from the program “despite frequently continuing to receive full Part D subsidies whose income and asset eligibility criteria align closely with Medicaid’s.”
  • A 2019 policy brief by the U.S. Department of Health and Human Services finds that “states with more inclusive Medicaid eligibility coverage policies tend to have less coverage loss among new, full-dual [eligibles] than states with more restrictive Medicaid coverage.”
  • The policy journal Health Affairs is a good source of research studies on Medicaid, Medicare and dual-eligible beneficiaries.
  • The nonprofit, independent health policy research organization KFF is a good source of data on Medicare and Medicaid and dual-eligible enrollees, including this January 2023 report on the profile of dual-eligible enrollees.
  • Here’s an in-depth data book on dual-eligible beneficiaries, published in January 2024 by the Medicare Payment Advisory Commission (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC).

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