Medicaid unwinding disrupted young people’s access to chronic disease medicines

Children and young adults with depression, schizophrenia, ADHD, asthma and epilepsy can get great relief from medications to control their symptoms, helping them stay in school or work and prepare for their futures.

But they should keep taking those medications regularly to get the best results; interruptions can cause flare-ups of these chronic health conditions.

Now, a study suggests that such interruptions happened more often in states that had the biggest drops in Medicaid enrollment during the recent “unwinding” process.

That process, which brought to an end the special Medicaid eligibility rules made at the start of the pandemic, began in April 2023.

However, states varied widely in how many people they disenrolled, because of differences in administrative processes and efforts to verify income-based eligibility.

The study, conducted by a team at the University of Michigan’s Susan B. Meister Child Health Evaluation and Research Center and colleagues, is published in the journal Pediatrics.

The team, led by CHEAR director Kao-Ping Chua, M.D., Ph.D., analyzed national prescription data for people age 0 to 25 using five classes of chronic disease medications before Medicaid unwinding began.

These medications are used to treat behavioral health conditions, breathing conditions, and seizure disorders.

They find that young adults ages 19 to 25 were more likely to stop filling prescriptions for these chronic disease medications if they lived in states that had the biggest drops in adult Medicaid enrollment, compared with those living in states with the smallest drops.

Children in the states with the largest drops in child enrollment in Medicaid or the Children’s Health Insurance Plan, known as CHIP, also experienced greater disruptions in therapy for certain classes of chronic disease medications, although the disruptions occurred less consistently than for young adults.

CHIP is open to children under age 19 whose family incomes are too high to qualify for Medicaid, but too low to afford private coverage. 

Significance for current Medicaid funding process

The new findings have significance not just for understanding the impacts of Medicaid unwinding, but also for the potential impacts of the cuts in Medicaid funding now being discussed in health policy budget debates.

“Our findings suggest that the rapid disenrollment of young people from Medicaid during the unwinding process resulted in the disruption of chronic disease therapy,” said Chua, a pediatrician and health care researcher at the U-M Medical School and School of Public Health. 

“As policymakers debate whether to enact major cuts to Medicaid funding, they should consider the possibility that doing so could similarly disrupt chronic disease therapy for children and young adults, placing them at higher risk for disease exacerbations and absenteeism from school and work.”

Effects based on state unwinding impacts

Chua and colleagues used data from a national prescription drug database from IQVIA, which captures 92% of prescriptions filled in U.S. pharmacies, including those paid with cash.

They also relied on data from the Georgetown University Center for Children and Families to calculate the percentage change in child enrollment in Medicaid and CHIP from just before the start of unwinding to the end of 2023.

The states with the biggest drops in child Medicaid enrollment (17% or more) were Arkansas, Georgia, Iowa, Idaho, Kansas, Montana, New Hampshire, Oklahoma, South Dakota, Texas, Utah, Wisconsin and West Virginia, and the states with the smallest drops (4% and less) were California, Connecticut, District of Columbia, Hawaii, Illinois, Kentucky, Maryland, Maine, North Carolina, Nevada, New York, Rhode Island and Tennessee. 

Oregon was excluded because its unwinding started later.

Children and teens who used asthma inhalers and lived in one of the states with the largest drops in Medicaid enrollment were more likely to decrease use of their medication.

In almost all cases, children and teens living in those states were also more likely to start using private insurance or cash to pay for prescriptions for the five chronic disease medication classes.

Among young adults, the researchers saw even larger effects.  

The young adult analysis excluded three states (South Dakota, North Carolina and Georgia) that expanded Medicaid for adults during the unwinding period.

The team used data on total adult Medicaid enrollment before unwinding and at the end of 2023.

The states with the biggest drops in adult Medicaid enrollment (19% or more) were Arkansas, Colorado, Idaho, Kansas, Montana, New Hampshire, North Dakota, Oklahoma, Texas, Utah, West Virginia, Wyoming. The states with the smallest drops (8% or less) were California, Connecticut, Delaware, Hawaii, Illinois, Maine, Massachusetts, Minnesota, Nebraska, Nevada, Virginia, and Wisconsin.

Young adults with prescriptions for any of the five chronic disease medication classes were more likely to stop filling these prescriptions if they lived in states with the highest versus lowest drops in adult Medicaid enrollment. 

Similar to children, they were also more likely to start using cash or private insurance to pay for prescriptions if they lived in states with high drops in enrollment.

Nearly 72 million Americans are currently enrolled in Medicaid after the end of the unwinding, and an additional 7.2 million children are enrolled in CHIP which also relies on Medicaid funding.

Ten states have not expanded Medicaid under the Affordable Care Act, but those that have done so offer coverage to all individuals up to 138% of the federal poverty level, or about $21,000 for an individual and $36,000 for a family of three.

Additional authors: In addition to Chua, the paper’s authors are U-M pediatrics research postdoctoral fellow Joanne Constantin, Ph.D., Genevieve M. Kenney, Ph.D., of the Urban Institute, Rena M. Conti, Ph.D., of Boston University and Kosali Simon, Ph.D. of Indiana University, Bloomington.  Chua is a member of the U-M Institute for Healthcare Policy and Innovation.

Funding/disclosures: The study was funded by CHEAR and by the National Institute of Health (R01DA056438, R01DA057284)

Paper cited: "Changes in Chronic Medication Dispensing to Children and Young Adults During Medicaid Unwinding," Pediatrics. DOI:10.1542/peds.2024-070380